The Northern Care Alliance NHS Foundation Trust v TB & Ors

This application is made in the Court of Protection by The Northern Care Alliance Foundation Trust (the Trust) and relates to TB, a much loved 19 year old man. Tragically, he is in a prolonged disorder of consciousness (PDOC) caused as a result of the catastrophic brain injury he suffered on 19 March 2025.

The Trust seek declarations that it is not in TB’s best interests for clinically assisted nutrition and hydration (CANH) to continue to be provided to him. The Trust also seeks a declaration that it is in TB’s best interests for CANH to be withdrawn and for him to be transferred to a hospice to be provided with palliative care.

The court heard oral evidence from the jointly instructed expert Professor Wade, Consultant in Rehabilitation Medicine, and TB’s father and sister.

The Trust’s application is agreed by TB’s mother, SB, and his sister, RB, who have attended the hearing in person.

Mr Wyard represents MB pro bono, for which the court is extremely grateful. At the start of this hearing TB’s father, MB, was unable to agree to the Trust’s application but did not intend to actively oppose it, or challenge the evidence of the medical professionals. He could not actively consent to the application, an action that he felt would amount to him having a hand in ending his son’s life. In his oral evidence, having heard and reflected on the evidence of Professor Wade, MB recognised the reality of the situation, and agreed that it is not in TB’s best interests for CANH to continue.

TB’s family are in a situation no family ever wishes to be in, each faced with such difficult decisions relating to TB in the context of losing someone who is so clearly loved by them all. They have each managed this hearing with a quiet dignity despite the deeply personal nature of the evidence the court is considering.

There is no issue between the parties that TB lacks capacity to make decisions about his medical treatment. The focus of this hearing is whether it is in TB’s best interests to continue to receive CANH. In the event that is the conclusion reached by the court there is agreement that TB should be transferred to a hospice and the contact arrangements with TB after that.

Despite the difficult relationship between TB’s parents due the breakdown of their relationship the family unite in their evidence about the kind of person TB is, in particular prior to his brain injury in March 2025. He has been described as an extremely active and intelligent young man with a wide variety of interests. He spent a lot of time on his physical fitness, had worked as a personal trainer and was learning to play the guitar and piano, with musical interests that extended to writing song lyrics. He had a lively social life and had plans to travel abroad with one of his friends. The oral evidence given by the family was both powerful and important, as they were able to bring to life what they had written in their statements about TB. TB’s father described TB’s personality which combined his natural intelligence with a sense of fun. He felt TB’s diagnosis of type 1 diabetes as a teenager during covid had been difficult. TB’s sister described him as a private person, to whom self-reliance was important and his physical fitness was because he wanted to be strong. He had suffered mental ill health in the past and had had to manage some difficult family and personal situations. TB’s sister spoke of the many long conversations they had had and his plans and wishes for the future. He was on the cusp of adulthood and had so much ahead of him when he suffered a catastrophic brain injury which tragically brought all those plans to a shuddering halt.

For the reasons set out in more detail below I have reached the very sad conclusion that it is not in TB’s best interests to continue to receive CANH and I approve the arrangements that have been agreed between the parties for TB to move to the palliative care plan. This conclusion is based on the medical evidence that TB is in a prolonged disorder of consciousness and there is no prospect of any improvement. In my judgment the considerable burdens of his continuing treatment where those burdens will only increase in circumstances where he has no awareness of his surroundings outweigh the strong presumption to preserve life.

TB had been living with his mother in the family home since October 2023. Prior to that TB had spent a period of time living with his father and prior to that also had a period of time detained in hospital under the Mental Health Act 1983.

TB was diagnosed with type 1 diabetes in 2021. His control of that diagnosis is described in the papers as being ‘sub optimal’, which resulted in a number of episodes of hypoglycaemia and an intentional insulin overdose.

In the days running up to TB’s injury on 19 March 2025 the records record an increasingly concerning picture of TB’s physical and mental health. This included him being found collapsed on the street due to him having not eaten all day, being admitted to hospital with a Glasgow Coma Scale (GCS) of 8/15, of him self-discharging against medical advice only to be found a few days later in a similar position, re-admitted back to hospital with a GCS of 3/15 and again self-discharging.

The following day the emergency services attended as TB had barricaded himself in his room in the family home and was not responding. It was necessary to enter the room by force and he was assessed as having a GCS of 10/15 and his blood glucose level was very low. He was taken to hospital and discharged himself against medical advice. He left hospital having disconnected his fluids while they were in the process of transferring him so they could detain him pursuant to section 2 MHA 1983.

The police were notified and managed to make some contact with TB at the family home.

The following day, 18 March 2025, TB is reported to have told a friend and his ex-partner by text message that he was going to end his life. Having been contacted by family and friends the police managed to locate TB. They took him to hospital as a place of safety pursuant to their powers under s136 MHA 1983. He was provided with some treatment and assessments (although not an MHA assessment) and TB left the hospital.

On 19 March 2025 TB checked himself into a hotel where it appears he took a further insulin overdose with alcohol. He was found by hotel staff and admitted to hospital. He had left a note.

On admission he had a CT scan which showed early hypoxic brain injury. He suffered a seizure, was intubated and ventilated and admitted to the intensive care unit.

TB had a repeat scan on 20 March 2025 which showed the progression of oedema in the brain. An EEG showed TB had severe encephalopathy which was confirmed by an MRI scan on 24 March 2025.

On 24 March 2025 TB was treated with antibiotics as it was thought he may be suffering from ventilator associated pneumonia. TB’s insulin regime was restarted. An MRI scan on that day confirmed ‘diffuse acute hypoglycaemic encephalopathy with some haemorrhage change in the left occipital lobe’.

On 25 March 2025 an EEG revealed severe widespread encephalopathy with signs of subclinical seizure activity due to ongoing seizure activity. TB was prescribed additional anti-epileptic medication.

On 28 March 2025 a further EEG showed a pattern indicating as high risk of seizures and his medication was increased.

He struggled to manage his airway so had a definitive airway management with percutaneous tracheostomy undertaken on 2 April 2025.

TB was seen by a neurology registrar on 3 April 2026 who observed flickering movements with pain stimulation. The pupils were dilated and unresponsive to light and no eye movements were seen during the oculocephalic reflex test.

TB had further CT head on 8 April 2025 which, when compared with previous scans, has shown evolving infarcts in the temporal and occipital regions.

TB was weaned off the ventilator on 12 April 2025 and transferred to the high dependency unit.

On 22 April 2025 a further EEG indicated no seizures and his anti-epileptic medication was reduced.

TB was examined by a Consultant Neurologist on 24 April 2025. At that time there were no eye movements in response to any stimuli, his pupils were fixed and dilated. TB blinked when his eyelids were stroked, and his corneal reflexes were intact. He was observed to shrug his shoulders, slightly flex his arms and move his jaw in response to painful stimuli.

A further MRI scan on 26 April 2026 concluded ‘extensive bilateral cerebral cortical and basal ganglia, as well as brainstorm areas of infarction with haemorrhage changes in the occipital regions as described, and further new areas of interval cortical infarction as mentioned. Significant bilateral hippocampal atrophy noted’.

On 25 May 2025 he was noted to open his eyes spontaneously and was observed as to whether he had a sleep-wake cycle.

On 28 May 2025 a percutaneous endoscopic gastrostomy (PEG) tube was inserted.

TB was transferred to another hospital on 5 June 2025 to the Hyperacute Neurological Rehabilitation Unit for formal assessment of his clinical state, particularly his level of consciousness. TB he remains on that unit.

TB was assessed in accordance with the PDOC National Guidelines between 21 July 2025 and 27 August 2025. This assessment concluded TB is in a vegetative state based on the Coma Recovery Scale – Revised (CRS-R) range from 3/23 to 4/23.

TB was also assessed using the Wessex Head Injury Matrix which was performed 10 times alongside the CRS-R assessment. A summary of the results indicated that he consistently open his eyes for more than 30 seconds during observation and that they moved aimlessly each time. The only other behaviour recorded on two occasions was teeth grinding. The behaviours observed were 2/63 on eight occasions and 3/63 on two occasions.

The report also notes that behavioural observations were made outside the structured assessments. This involved 150 observation periods lasting 10 seconds each. The observations made using structured assessments were entirely consistent with those made by care staff over the same period.

A further assessment was undertaken on 11 February 2026 when the total score was 6/23. The observer recorded ‘the assessment does not indicate any significant change since the formalised assessment six months ago. Although the total score was marginally higher overall, this was due to him demonstrating behaviours that he has previously demonstrated but happened to demonstrate them all within one session today. The responses continue to indicate reflexive and spontaneous behaviours only and indicates that he remains in a vegetative state with no changes noted. No purposeful behaviours demonstrated no evidence of any functional communication.’

The clinical team have liaised with the family. A meeting was held with SB and RB in September 2025 to discuss the outcome of the PDOC assessment.

A best interest meeting took place on 13 November 2025. MB wrote a letter before that meeting. He did not attend the meeting. In that letter and since MB has set out what he considers to be TB’s progress, his concerns about lack of stimulation for TB and that he is unable to accede to the Trust’s application.

SB and RB did attend the November meeting. They are recorded as follows regarding TB’s likely wishes ‘Sister feels he would not have wanted to live like this now he is requiring 24 hour care, having a tracheostomy, having contractures, and requiring all his personal needs being supported by other people. Mum feels he wanted to live a larger-than-life presence, so would not have wanted to continue the way he is now. Following the discussions the decision at the end of the meeting is recorded as follows: ‘We all feel, listening to the discussion that happened in the best interests meeting by all those present here, that the patient would not have wanted to continue to live. He was a young fully independent person prior to this insult to the brain and he is at the moment completely dependent on others to provide his personal care, medications and supported with a tracheostomy for his breathing and assisted nutrition and hydrations for maintaining his life, and we feel that from discission with his mum and sister with whom he has lived all his life that the patient would not have wanted to continue living a life like this’.

The court has the written statements from Dr P, Consultant in Rehabilitation Medicine, who is the clinical lead who confirms the history set out above and the conclusions reached by the Trust in bringing this application. In his most recent statement he reports there have been no significant changes in TB’s condition.

The statement from JL, Specialist Neuro Occupational Therapist and Expert PDOC Assessor, details the PDOC assessment that was undertaken in July and August 2025 and updated in February 2026.

The statement from HH, Band 9 adult nurse, details TB’s day to day care. He confirms TB receives his medication primarily via his PEG. He details the daily tracheostomy care and the need for suctioning between 1 – 6 times a day, TB’s cough is a reflexive act and due to the spasticity in his neck a cough causes quite a significant body movement. He describes TB as presenting the same way whatever his care as being ‘expressionless and motionless with his eyes fixed ahead’. He has never witnessed him respond to voice, music, faces or other stimuli. His statement details the fourteen infections TB has had since June 2026 that have required antibiotics. He also details the complexities in TB’s day to day care caused by his increasing spasticity.

The statement from Dr C, Consultant in Palliative Medicine, set out the plans in the event that the application to withdraw CANH is granted. It could not take place on the ward where TB currently is and he would need to be moved to a specialist nursing home or hospice where specialist teams and support are available for TB and the family. In her statement she sets out the practical arrangements that would take place if the court makes that decision and her statement exhibits the relevant national and regional guidance that applies in these circumstances.

The statement from LMM, Neuro Rehabilitation Complex Discharge lead Nurse, provides further details regarding the palliative care plan and how the clinical team would work with the local authority and Integrated Care Board to establish funding responsibilities for TB’s ongoing care and will liaise with the family about those arrangements, including ceiling of care in the community.

The statement from LM, Registered Nurse, confirms she has been involved in TB’s care since February 2026. She was present when the representative from the Official Solicitor attended to visit TB. LM makes it clear she is not qualified to interpret TB’s responses. The statement from LL, Assistant Practitioner on the ward where TB is makes clear she is not qualified to interpret any of TB’s responses.

TB’s family have provided written statements.

SB repeated the view she expressed in the best interests meeting in November 2025. She does not consider TB would want his life to continue in the circumstances he now finds himself in. SB feels she can say that as he had seen the suffering of family members who had both had dementia and had spoken about not wanting to continue life if he found himself in that position.

RB’s statement set out from her experience of TB he had a ‘strong sense of autonomy and valued his privacy’, it was important to him to be seen as ‘strong, capable and self-reliant’.She said TB loved going out and invested a lot of time and energy in his friendships. RB also reported having discussions with TB in the context of family members having dementia and how they had both agreed that they would not want their life prolonged in such circumstances and she felt that view would apply to the situation TB finds himself in now. RB said TB ‘placed great weight on independence, mental clarity, physical capability, and close, reciprocal relationships. In my view, he would value those things over the mere fact of remaining alive in circumstances he had described as intolerable, especially where, as the clinicians have told us, the prospects of meaningful improvement are very limited’ and that his current circumstances would be like a ‘living hell for him’. In her oral evidence she described his ability to easily pick up new things, their discussions about the future and his love and interest in music.

In his statements MB reports his belief that TB is improving although acknowledges that TB ‘would not want to go on indefinitely if his condition were not to improve from where he is currently. However, he would want the opportunity to try, he would want to benefit from the right treatment in terms of attempting to bring him on and not just leaving him to his own devices and nature. I believe he will wake…’ . He then describes the level of recovery that TB would want stating B would ‘still be able to do the things he loves and live a life he would want to live’. In his oral evidence, having heard the evidence from Professor Wade, he accepted that there was no prospect of TB improving and the application by the Trust is the right decision.

The representative from the Official Solicitor visited TB on 20 April 2026 providing a note of what was observed during that visit.

Professor Wade, Consultant in Neurological Rehabilitation, is the joint expert. He visited TB on 28 April 2026. He met some of the clinical team and MB with one of TB’s friends. Separately Professor Wade met SB and RB. He saw TB separately and then with the family, separately.

In his report Professor Wade concludes TB has suffered severe brain damage with no significant area of the brain remaining undamaged. He notes that the extent of the brain damage was seen in the CT scan within 24 hours of the incident. TB has prominent spasticity with high muscle tone which has led to contractures, shortening of muscles and tendons around the joints, making it difficult or impossible to move joints through their full range of motion. TB is unable to swallow or protect his airway and has no control over his bowels or bladder.

As regards TB’s levels of consciousness the spectrum of responsiveness is used in the internationally used measure of consciousness in acute illness, the Glasgow Coma Scale. The score ranges from 3/15 (coma) to 15/15 (fully conscious). Professor Wade concludes that TB is ‘undoubtedly at the lowest end of the spectrum of responsiveness and of consciousness. It is plausible that there are slight differences in his response to his father due to associated emotional reactions and connections to his father’s presence, thought the examples I have been told about are not convincing. It is implausible that he has any self-consciousness, awareness of himself as an individual’. He further concludes regarding TB’s experience of pain that TB experiences an ‘unpleasant feeling akin to pain when subject to some care procedures, particularly suctioning. These feelings will not be remembered, not least because he had been demonstrated to have severe damage to his hippocampi, and this damage is known to be associated with severe amnesia for events. Furthermore, he will not anticipate the occurrence of pain because he will not remember the precedents of the painful stimuli’.

Professor Wade does not consider any further investigations need to be undertaken. In his opinion TB’s clinical state has been fully recorded during the whole of his illness. He has been assessed many times and those results accord with the clinical observations. He also concludes that there would be no benefit from any change in TB’s care environment, including any form of physical therapy, sensory stimulation, or similar therapies.

Professor Wade is clear that no significant, detectable, sustained improvement has been observed over a fourteen month period and the instances of behaviour reported by MB in Professor Wade’s opinion ‘fall well within the typical range of variation and spontaneous behaviour seen in unconscious people’. He considers there is no prospect of TB improving and it is likely his worsening will continue, such as increasing problems with spasticity, postural deformation, at risk of seizures, recurrent chest infections and increasingly burdensome care. As he states in his report TB will never:

Professor Wade concludes in his report that continuing CANH is not in TB’s best interests. His oral evidence confirmed the detail set out in his report.

The Trust have very helpfully filed a detailed legal framework which no party takes issue with.

As set out there is no issue that TB lacks capacity to make decisions regarding her medical treatment in accordance with the provisions of ss1 – 3 Mental Capacity Act 2005 (‘MCA 2005’)

The focus in this hearing has been on what is in TB’s best interests.

The statutory best interests ‘checklist’ under s 4 MCA 2005 provides:

The first question which the court should ask itself is whether it is in TB’s best interests to continue to receive clinically assisted nutrition and hydration (CANH). The second is whether it is in TB’s best interests to receive palliative care. In Aintree v James[2013] UKSC 67 Baroness Hales stated at [22]:

“The focus is on whether it is in the patient's best interests to give the treatment, rather than on 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 that they have acted reasonably and without negligence) the clinical team will not be in breach of any duty towards the patient if they withhold or withdraw it.”

The classic statement of how the court should undertake this task in reaching a decision as to what is in the person’s best interests under the MCA 2005 is set out by Baroness Hale in Aintree University Hospital NHS Foundation Trust v James [2013] UKSC 67 at [39] – [45].

The MCA 2005 Code of Practice (‘the Code’) issued under s.42 MCA 2005 came into effect in April 2007. Chapter 5 of the Code titled ‘How should someone’s best interests be worked out when making decisions about life-sustaining treatment?’ includes the following guidance:

“5.38.

In setting out the requirements for working out a person’s ‘best interests’, section 4 of MCA 2005 puts the person who lacks capacity at the centre of the decision to be made. Even if they cannot make the decision, their wishes and feelings, beliefs and values should be taken fully into account – whether expressed in the past or now. But their wishes and feelings, beliefs and values will not necessarily be the deciding factor in working out their best interests ...”

“5.41

The person may have held strong views in the past which could have a bearing on the decision now to be made. All reasonable efforts must be made to find out whether the person has expressed views in the past that will shape the decision to be made. This could have been through verbal communication, writing, behaviour or habits, or recorded in any other way (for example, home videos or audiotapes)”

“5.47

Section 4(6)(c) of the Act requires decision-makers to consider any other factors the person who lacks capacity would consider if they were able to do so. This might include the effect of the decision on other people, obligations to dependants or the duties of a responsible citizen.”

In a case of this kind, the fundamental 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 Airedale NHS Trust v Bland[1993] AC 789at [808], "A profound respect for the sanctity of human life is embedded in our law and our moral philosophy”. More recently Hayden J stated in Guy’s and St Thomas’ NHS Foundation Trust v A (a child) and others[2022] EWHC Fam 2250 at [41] “There is unique value in human life, frequently referred to as the ‘sanctity of life’. That does not dissipate where awareness diminishes, or the capacity of the brain becomes so corroded that all autonomy is lost. It is perhaps in these circumstances that it requires the most vigilant protection. …”

It is clear that wider considerations than merely clinical ones are engaged in cases of this nature and by definition these cases are highly fact specific.

A helpful list of issues requiring determination in an application of this kind were set out by Cobb J (as he was then) in PL (by her litigation friend, SL) v Sutton CCG & Anor[2017] EWCOP 22at [9]; namely:

All parties now accept that it is not in TB’s best interests to continue to receive CANH.

The evidence establishes that TB’s level of awareness and consequent diagnosis is clear.

A combination of the clinical medical evidence and the opinion of Professor Wade support that court concluding that TB has suffered a severe widespread brain injury and that he is now in PDOC. The consensus of the medical evidence is that TB is at the lowest end of the spectrum with regards to consciousness and that he does not exhibit any behaviours consistent with any level of awareness. Understandably some of TB’s behaviours may appear to suggest a level of awareness but Professor Wade was clear in his written and oral evidence, which I accept, that the behaviour reported falls within the typical range of variation and spontaneous behaviours seen in unconscious people.

The medical evidence is also clear about TB’s prognosis. There are no further steps that can be taken that would bring about any improvement in TB’s condition. Looking forward TB’s contractures are very likely to increase with the consequent difficulties in being able to manage his care, the increasing risks of infection and a possible consequent increase in feelings associated with pain/discomfort. If CANH continues he could live for a number of years.

In relation to TB’s wishes and feelings, beliefs and values the information from the family supports the conclusion that TB would not want to live in the way he currently is, he would not be comfortable with the level of care he requires and would not want to exist in the way he had seen happen to relatives. The evidence establishes that TB would consider his current position as being the antithesis of not only his previous life but everything that is important to him, in particular his family, his friends and his relationships.

In assessing the burdens and benefits of TB’s condition and treatment the court must and should place significant weight on the sanctity of life, that TB is being well cared for, is loved by his family who continue to visit him and that CANH is not futile in that it is keeping him alive. However, the evidence establishes significant burdens which include TB having no conscious experience of himself or his environment. His condition, daily care and treatment is burdensome. There is an increasing risk of infection. TB’s quality of life now is the opposite of everything that is important to him, there is no prospect of improvement, it is very likely he will deteriorate with increasing contractures and any feelings he has of discomfort and pain are likely to increase as his condition deteriorates. TB has no conscious experience of himself or his surroundings which is not going to change, and so the burdens to him when weighed against the benefits lead to the conclusion that continuing CANH is not in TB’s best interests.

For the reasons set out above, with enormous sadness, the declaration sought by the Trust that continuing CANH for TB is no longer in his best interests is granted.