Mr Justice Hayden :
This application concerns JP, who is 64 years of age. On 15 th January 2016, JP suffered a ventricular fibrillation cardiac arrest. He had been feeling unwell that morning and had mentioned this to his son (TP). Nonetheless, he cycled to work as usual. JP was a man who very rarely missed work due to illness. He was a keen cyclist, often cycling at weekends with his brother. JP was also a fit man who worked out regularly at his home gym. Despite this, he suffered from hypertension for which he received medication. On the way to work, he collapsed at the roadside, by his bicycle and suffered a severe hypoxic brain injury. At least 25 minutes passed before the return of spontaneous circulation following defibrillation. JP was admitted to St Thomas' Hospital where imaging revealed anoxic brain injury. JP was intubated in ITU but later had a tracheostomy inserted as he was experiencing aspiration pneumonia. He became self-ventilating on 24 th January 2016.
On 21 st April 2016, JP was transferred to the Royal Hospital for Neuro-disability (RHN) to the Brain Injury Service (BIS). The purpose of the transfer was for assessment and disability management. A percutaneous endoscopic gastrostomy tube (PEG) was inserted prior to JP's transfer and has remained in situ to date. In August 2016, he was transferred to a General Practitioner led ward at the RHN. The ward is effectively run as a nursing home rather than a hospital. The RHN is not part of any NHS Trust, it is a charity.
Dr Andrew Hanrahan was JP's Consultant Neuro-Rehabilitation Specialist whilst he was with BIS between April and August 2016. He re-examined JP on 6 th January 2025, for the purpose of providing up-to-date evidence for this court. Professor Lynne Turner-Stokes, Consultant in Rehabilitation Medicine has filed an independent expert report, having examined JP on 4 th December 2023 and prepared a supplemental desktop-based report on 10 th January 2025. Dr Hyder, JP's GP has prepared a statement which has been filed in these proceedings, dated 8 th March 2024. Each of the Clinicians has concluded that JP has been in a prolonged disorder of consciousness (PDOC) since his injury in January 2016. Dr Hanrahan describes JP as being in a "permanent vegetative state (PVS)" . All agree that term is used accurately. Dr Hanrahan, recognising that it is a term that can generate distress, explained in oral evidence that he used it to indicate compliance with the National Guidelines prepared by the Royal College of Physicians, October 2020 (these are now pending review). Dr Hanrahan reported that this was also a term used repeatedly with JP's family and with which they were familiar. In North West London Clinical Commissioning Group v GU [2021] ECOP 59 , I deprecated the RHN's inaction and the unsupportable delay in failing to assess GU's best interests. I expressly endorsed the submission made on behalf of the Official Solicitor, representing GU to the effect that:
Mindful that GU had been in PDOC for 7 years, I emphasised that:
In that case, as in this, the RHN made no attempt to justify the delay in 'best interests' decision taking, nor there, as here, did they seek to proffer explanation which might have justified the delay in bringing the matter to court. In neither case could they have done so. I also record that they have made a clear and unambiguous apology to JP and his family. I have received cogent and compelling evidence that JP, notwithstanding his religious beliefs, would not have wished to have been left as he has been. I also record that these views had become known to the RHN many years ago, most explicitly through what JP's partner of thirty years had told them. Sadly, JP's partner died in 2022. My focus, in this judgment, is unswervingly on JP. I do not, therefore, propose to say anything further about the delay. I will do so in a separate judgment at a later date. I do, however, consider it important to repeat my observations in GU (supra) as to the obligation on all those concerned to have regard to the centrality of respect for human dignity.
Recognising the challenge of identifying unifying principles underpinning the concept of human dignity, I drew the following themes from my survey of the international texts and instruments:
I analysed the legal framework extensively in GU. I do not propose to repeat it here, each of the advocates, having framed it as the basis for this application.
Professor Turner-Stokes concluded in her Supplementary Report, dated 10 th January 2025:
I have been told that JP remains entirely dependent on nursing care, including in the management of his double incontinence. He has not required any recent significant medical intervention. His skin is fragile but intact. He demonstrates, on the consensus of medical evidence, only the most low-level responses. These are either spontaneous or reflexive, with no evidence of localising or purposeful behaviours. Dr Hanrahan told me that in consequence of a spinal cord reflex, information may be transmitted to the brain. It is the brain, not the spinal cord, that is responsible for the integration of sensory information. The spinal cord may elicit some basic reflexes and those responses are transmitted via motor neurons. This is most likely, having regard to the broad canvas of the neurological evidence, to be an entirely understandable misinterpretation of the reflexive responses. JP's eyes are mainly closed, opening briefly in response to stimulation.
Some similarly brief abnormal extensor movement has been observed in response to pain. An auditory startle response has been noted but no "visual startle" . The various assessments that have been conducted to evaluate the level of consciousness, i.e. the validated tools of the Wessex Head Injury Matrix (WHIM) and Coma Recovery Scale (CRS-R) have demonstrated only three behaviours over a 10-minute period, the highest being Item 2 of 62 ( "Eyes open for an extended period" ). The medical consensus is that JP can probably not experience pain, however, it is impossible to be certain. The fact that it is impossible conclusively to discount experiencing pain weighs particularly heavily with TP (JP's son). TP told me, in evidence, how terribly his mother had suffered with pain in her own protracted illness, and how much distress it had caused him, his father, and the family. TP reported his father saying: "living like that is like living in hell" . He went on to say that his father added to that: "I would never want to go through that" . I recognise that there is an elision here between TP's own views and those he believes to be shared with his father. However, as others also relate JP making similar comments, I find that TP's account is a reliable articulation of his father's views.
Both Professor Turner-Stokes and Dr Hanrahan have concluded that clinically-assisted nutrition and hydration (CANH) is a 'futile' treatment for JP. This requires to be understood. CANH will preserve JP in his present condition. With CANH and good nursing care, Dr Hanrahan is of the view that JP's actuarial life expectancy could be between 5 and 10 years. However, CANH will not reverse his profound brain injury, nor restore him beyond his presently disordered consciousness, which has persisted for 9 years. It will most decidedly not restore him either to the person he was or to the life he enjoyed, with such vigour, prior to his brain injury. Alongside this, it is necessary to balance the obvious burdens of continuing treatment, which include the difficulty in managing his PEG and tracheostomy site. JP requires 24/7 care to keep him stable which is burdensome for him. In addition, JP requires care for the ongoing challenges of his cardiac condition and any acquired infection.
On withdrawal of CANH, JP will not survive longer than between one and three weeks. The following list summarises the Proposed Palliative End-of-life (EoL) Care Plan:
(i) The PEG tube will remain in place, but will not be used for any access whatsoever;
(ii) Tracheostomy interventions will be minimised;
(iii) Unnecessary medications (e.g. antihypertensives) will be stopped;
(iv) Anti-epileptic medications will be stopped and replaced with an appropriate dose of Midazolam, given through a 24-hour continuous subcutaneous syringe-driver;
(v) Glycopyrronium will be stopped in the first instance, but will be added to the syringe-driver if secretion management becomes problematic;
(vi) Morphine sulphate 1.25-2.5 prn SC/IM up to 1 hourly will be prescribed for pain or shortness of breath;
(vii) Midazolam 2.5mg SC prn 1 hourly will be prescribed for agitation/distress/second line for shortness of breath, or 5-10 mg SC prn up to 1 hourly for seizure activity; and
(viii) Spiritual care and bereavement support will be provided as needed by the RHN Chaplain and Bereavement team. This will involve contact with the Pastor who the family would wish to contact.
Expressly, Dr Hanrahan concludes "it is no longer in [JP]'s best interests, and has not been for some time, to continue to receive CANH" . Professor Turner-Stokes agrees. The medical evidence permits of no real challenge, as the family have largely recognised. JP's daughter (VP) plainly loves her father deeply, but some three years ago, she stopped attending the hospital. She told me that her father was "simply not there anymore" . She described him as having become "unrecognisable" . Dr Hanrahan also commented on his recent physical decline.
However cogent and compelling the medical evidence may be, it is always important to recognise that medicine evolves and develops. Both the Court of Protection and the Family Court have experienced this over the years. The case law in both jurisdictions is testament to it. Today's medical shibboleths may become tomorrow's heresies. It is important therefore, where necessary, even for a strong consensus of medical opinion to be put to the assay, especially where the consequences of accepting the opinion are so profound. Ms Paterson KC, on behalf of the Official Solicitor, has tested the evidence thoroughly and sensitively, primarily to assist the family in their understanding of JP's medical circumstances. The medical evidence is never determinative. Where there is a conflict, it is the Court's obligation to resolve it. As has been said, it is judges not doctors who are charged with the responsibility of deciding cases.
In resolving a 'best interests' decision, the judge must always consider the broader evidential canvas and the imperative to determine, to the extent that it may be possible, what the protected party (P) would want for themselves. JP did not make any advanced decision, and so it is his family who must be the conduit by which his views are understood and articulated in the courtroom.
This has been a hybrid hearing. JP's mother and sister have attended via video link from Jamaica. TP (who now has children of his own) attended (remotely) from Michigan, USA. JP's cousin gave evidence from Birmingham. JP's sister (OP) and JP's daughter (VP) gave evidence in the witness box in the courtroom. Her youngest sister sat beside her during the course of the case, both live at home and are plainly very close. Additionally, JP's other sister attended via a link from Manchester.
JP was born in December 1960, in England, to parents of Jamaican origin. He was the second of nine children, only six of whom survived early infancy. JP's mother returned to Jamaica with her children when JP was five years old. Her husband continued to work in the United Kingdom for a number of years and then followed her to Jamaica. JP's father was a Deacon of the Church of the New Testament of God, where his mother, sang in the choir. He remained in Jamaica until he was fifteen years of age; attending school there. The family lived on a farm. JP's sister describes him caring for the family's animals, which consisted of " pigs, chickens, goats, cows, donkeys, dogs, cats and one hundred pigeons ." I have been told, from his family, that his interest in the natural world, both plants and animals, was life long and one of his greatest pleasures, second only to his family.
When he was fifteen, JP returned to England and lived with his uncle in Birmingham, who was also a pastor in the Church of the New Testament of God. JP remained there until he was nineteen years old. I note that regular attendance at church was part of the family's weekly routine. After completing secondary education here in the UK, JP trained to be a welder at a college of higher education and then worked with his uncle. In fact, JP went on to spend much of his adult life working in the hotel industry, undertaking various skilled jobs such as electrical repairs.
Notwithstanding the tradition in his family, JP drifted away from organised religion. That is not to say this reflected any diminishment in his faith or values. He chose instead to pray when alone and would take himself off to do so. Neither was this a choice to keep his faith private. He would tell people when he was going off to pray. He would also read passages from the Bible to his children. The children remember this with affection and, it struck me that they too shared their father's faith in a similar, though evolved way.
JP had two long term relationships; the first with B, the mother of his two elder sons, EP and FP and the second with T, with whom he remained for thirty years and had three children; TP, VP and AP. After the relationship with B ended, JP moved from Birmingham to London, where he lived initially with his brother, CP, with whom he was very close.
Throughout his life, JP maintained regular contact with his extended family. They all describe his integrity, strong work ethic and sense of discipline, which they hinted bordered on perfectionism. He liked to get things right and enjoyed the opportunity to do so that his work provided. All this, however, was counter-balanced by his wide range of interests and obvious sense of fun. He was, I have been told a keen Marvel fan who collected comics. He liked to tease his family about having "superpowers" , his favourite character was "Wolverine" , who I have been told is a very physical character, as JP plainly was himself. JP's children have clearly given much thought and reflection to what their father would have wanted. They have recalled how in his conversations with them about the Marvel Universe, he referred to a character called "Professor X" . Professor X had been a wheelchair user, who it transpires got into battle with Cyclops and survived only by transferring his consciousness into the mind of a comatose man. They told me how JP said on several occasions that he would never choose to have that power, even if he was stronger than the rest, because he values the physical aspect of life most. It is not difficult to see why this now resonates with JP's children. It may have little, if any, significance by itself, but it does factor into the wider evidence illuminating JP's own likely wishes in his present circumstances.
JP has been described to me as having a fierce sense of independence. He was always determined to accomplish tasks on his own. His drive for self-reliance was evident in how he approached challenges, preferring to solve problems without assistance. This trait is not described as a mere preference, but rather as a deep-seated value, reflecting his belief, almost as an article of faith, in the importance of personal effort. Even when challenged, he would try to find a solution on his own, sometimes preferring to leave a task at least temporarily unfinished rather than seek help.
As Ms Paterson has observed, perhaps the most strikingly consistent feature of the accounts is his unremitting devotion to the care of his late partner, T. He cared for her throughout a lengthy illness, while looking after the children and working full time. I agree with Ms Paterson's observation, to the effect that JP's partner and family were the centre of everything he did. All agreed that he was lucky to have had such a happy relationship, and that he recognised and appreciated his good fortune.
In these proceedings, the family have proffered their views in writing. The extent of their careful reflections really requires me to set these out in some detail. TP (son), VP (daughter) and AP (daughter) expressed their shared views:
What I find particularly impressive about this passage is its striking maturity, but even more than that, I am struck by the way they engage with the central issue. These young adults phrase the question not as to whether CANH should be withdrawn, but as whether JP would "prefer not to undergo prolonged medical intervention that doesn't lead to a significant recovery or allow him to live as he once did." This is precisely the way the question requires to be formulated. It echoes the careful passages of Lady Hale in Aintree University Hospital NHS Foundation Trust v James [2013] UKSC 67 at [22]:
JP's eldest son, EP expresses very similar views when he spoke to the representatives of the RHN in 2023. Again, EP engages with the benefits of giving the treatment, concluding as others have, and as I have set out in the passages below that he would have stopped this treatment long ago because his father would not have wanted it. EP is engaging directly with what he thinks his father would want now, and how that would be in his best interests. The full note records:
JP's brother (CP) has recorded as giving the following views:
Two of JP's sisters KP and IP, and his mother proffer a very different view:
JP's niece (DP) shared the views of her mother, aunt, and grandmother:
As EP (son) anticipated, those family members who hold a strong Church based faith have struggled with identifying JP's best interests in any terms other than his faith. Their own faith delivers them certainty as "children of God" , who alone "can give life and take it" . It permits of little ambiguity and reflects a facet of faith which emphasises belief with complete trust and strong conviction. This thinking is reflected in many religions and is certainly encountered in the Judeo-Christian tradition. Faith is, however, elusive to prescriptive definition. It is also frequently characterised as a 'grace' or 'gift from God' which imposes an obligation to struggle and to seek understanding. These two concepts generate an obvious tension.
This is a tension which JP's children have identified and grappled with. Each of them has reviewed the code and principles by which their father has lived his life, explicitly recognising the importance and centrality of his faith to him. Their views are all focused on him and directed to the central question of his best interests. By contrast, some of the other members of the family provide few, if any, illustrations of why they consider that JP would wish to wait until "God was ready" . Equally notable is the presence of the first personal pronoun in the expression of their views. Strikingly, they talk of 'I', and not 'him'. I hope they do not regard that as a discourteous observation, it is certainly not intended to be. Such is the strength of their own faith, that they struggle to contemplate that JP might have landed, as a consequence of his life experiences, at a different point on what is a spectrum of belief.
JP's children have not only been able to recognise this, but they have also identified evidence which supports and illustrates their father's views. I find, as I have foreshadowed, that the exercise they have been engaged with has been rigorous, sensitive, and reflective. It is also a matter which they have considered over a significant period. I am left with the clear view that it is their analysis and evidence which most accurately reflects JP's authentic wishes and approach to life. They are extremely impressive young people, features of their father's personality, as it has been described to me, ripple to the surface in the evidence of each of them and in different ways. In some ways, perhaps paradoxically, this serves to reveal JP's views even more clearly.
To the above must be added a paragraph from the report of Dr Hanrahan dated 8 th January 2025:
The remark, in parenthesis, in the above paragraph reveals, in my judgement, the consistent sensitivity that Dr Hanrahan has shown to his patient. Neither can there be any doubt that JP's physiological resilience reflects the very high quality of the nursing care that he has received. Dr Hanrahan is right to highlight, in my view, that JP is "more than just his body" . Though he has no level of awareness, his human dignity is respected and protected by all around him. Poignantly, all those involved with JP, both family and professionals, have alighted on a particular incident, which is both moving and intensely personal. Indeed, it is so personal, in context, that I have hesitated to include it within this judgment. However, it is part of the evidential canvas that has been so frequently referred to, that to excise it from the judgment would be remiss.
JP's partner, because of her arthritis, was unable to braid her daughters' hair. Braiding in this community is not simply a matter of style or beauty, it is an assertion of culture. JP took on this responsibility. This is no small task. It took most of the day, once every three weeks, for both girls, i.e. a day each. It is, in its own way, a testament to JP's love and commitment to his daughters and it says so much about him that is too obvious to require comment. As the sisters told me, none of their other friends' fathers, of his generation, ever became involved in this task. It is also obvious that JP enjoyed it. He told his girls that their hair was "their crowning glory" . The children had an affectionate name for their father, they called him "the lion" . This was due to his mane of dreadlocks. There is little doubt that JP was very proud of his locs (I adopt the family's preferred spelling) and took great care with them. They were intrinsic both to his identity and to his culture. It was also hinted to me that there was an element of male vanity involved. This was said humorously and accompanied by a reminiscence of JP's enthusiasm for being on trend with the right jeans and trainers. VP (daughter) told me that he aspired to be a "cool dad" .
JP retained his locs following his accident, but a few years ago, it became impossible to manage them in his circumstances. VP told me her father's locs fanned against the pillow of his bed when she visited him. A decision was taken that they would have to be cut off. This decision was arrived at with fastidious sensitivity, everybody reluctantly agreeing that it was necessary. It is plain, however, that it signalled to the family, and perhaps more widely, the final departure for JP from the man he had been. All agreed he would have hated this. He is unrecognisable now. The sensitivity of all involved, at least to my mind, guarded JP's dignity. I am, however, left with a sense that he may not have agreed with this view.
My summary of the Proposed Palliative End-of-life (EoL) Care Plan (see Para. 12 above) reveals both the thought and expertise that has been put into it. It provides for the discontinuation of medications not necessary at the end of life; it minimises tracheostomy interventions; as pain cannot be definitively excluded, it provides for Midazolam subcutaneously and continuously, supplemented by Morphine Sulphate when required. As Dr Hanrahan has explained, the nutrition and hydration received by JP at present, is involuntary. There will be no instinct for either at the end of life. This plan is constructed to provide a peaceful and dignified death for JP, with a real prospect of his family by his side, if they feel able to be there.
Having surveyed the full panoply of both the lay and medical evidence, I have come to the clear conclusion that it would be contrary to JP's best interests to be provided with hydration and nutrition at this stage in his life. Such treatment would be both futile and burdensome, and, I am satisfied, particularly on the evidence of his children and late partner, not what he would have wanted. I note that the ICB remained neutral on the application but stated in its closing submissions that "it would find it difficult to see that JP would have considered it in his best interests to continue to live life in his present condition indefinitely without any realistic prospect of improvement" . I record for completeness, though it is clear from the analysis above, that the Official Solicitor has, from the outset of the hearing, also supported the Declaration on JP's behalf that CANH is not in his best interests.