Royal Free London Hospital NHS Foundation Trust v RH & AH

Summary

This application related to ‘RH,’ who was 35 years old. The Trust sought orders to set ceilings of treatment on RH’s renal replacement therapy, mechanical ventilation and attempts at CPR. The clinicians would be allowed to escalate beyond these ceilings of treatment if clinically indicated, but would have the court’s consent not to do so. This position was broadly supported by the Official Solicitor acting on behalf of RH, and opposed by RH’s mother, AH.

RH had a history of liver disease for which he had received significant treatment since childhood (including a liver transplant in his teen). Sadly, RH developed liver cancer in 2024, and his health deteriorated further. In December 2025, he had a further liver transplant, which was a complex procedure involving major bleeding. His health deteriorated further the surgery, and even following multiple rounds of invasive intervention, ‘by the end of February/beginning of March 2026, RH was critically ill, very frail, experiencing delirium and ongoing abdominal sepsis infection, requiring mechanical pressure ventilation by a tracheostomy, intravenous nutrition and antibiotics. He was subject to an ongoing large bile leak. He was permanently bed bound. Thereafter, RH deteriorated further with oxygen desaturations, rising inflammatory markers, worsening renal functioning and fluid overload. He had a collapsed lung and required an emergency bronchoscopy.’ [17] An MDT in February 2026 concluded that RH was dying, and the decision ‘was to carry out no further or new interventions (vasopressors, renal replacement therapy, significant increase in ventilator support and cardiopulmonary resuscitation), but ongoing treatment would continue.’ RH then deteriorated further in March 2026, and clinicians did not think any other treatment options were available. RH’s family opposed his being put on a palliative care regime and asked the hospital to make a court application. Notably, the hospital’s decision to bring an application appears to have been based at least in part on the Townsend decision in the Court of Appeal:

22…The doctors received legal advice in the light of the Townsend case that treatment should be given to save life while the dispute was resolved and accordingly vasopressors for blood pressure support, and renal replacement therapy were instigated, along with the mechanical ventilation. The introduction of RRT caused significant blood loss. But within two days, RH was weaned off mechanical ventilation, and placed on a relatively low sedative dose. For a few hours on 24 March 2026, the sedative was completely stopped, but RH said he was in pain and it was restarted.

However, the hospital ultimately confirmed that it was willing to make the treatments available if ordered by the court, and Peel J considered that the effect of Townsend on the present case was ‘marginal’ (paragraph 56).] The judgment did not engage with Townsend or make any findings in respect of it.

Further evidence was sought on capacity in light of concerns that RH was sedated and had fluctuating states of consciousness and delirium – RH did not appear to have any pre-existing conditions to his severe deterioration which would have led to his capacity to be challenged. When further evidence was obtained, RH was so unwell and struggling to sustain consciousness long enough to discuss his care that the parties ultimately agreed he lacked capacity.

On best interests, the clinical evidence was that RH was in multi-organ failure, was dying and was experiencing pain or discomfort when being administered the treatments for which the Trust sought ceilings of care. AH held the view that RH would recover and felt he was much improved since receiving renal replacement therapy. She considered that he was experiencing discomfort but did not think he was in pain. She considered he would want as much time with his family as possible, and would want as much treatment as possible.

Peel J accepted the unanimous evidence that RH had no prospect of recovery, and the family’s hope was for a medical miracle which in the judgment of the court “can be all but discounted” (paragraph 48). Peel J considered that “[t]he medical context of this application is therefore RH’s irreversible condition, his progressive deterioration and his very short life expectancy” (paragraph 48).  Peel J did not consider it appropriate to treat the current care as a ‘threshold’ from which care should be considered, and the matter needed to be looked at holistically. RH did not appear to be in intolerable pain, but was experiencing pain and discomfort on interventions. His current overall picture was one of drowsiness and low consciousness. Peel J accepted that continuing time with his family was a benefit to him, but

52. [s]et against the benefits to RH and his family of their precious times together are the many current and potential future burdens of invasive treatment. Nobody disputes that RRT, mechanical ventilation, vasopressors (maintained by a central line), and other intravenous-based treatment are burdensome. He, in my judgment, experiences not just discomfort, but confusion, delirium and pain as well, particularly from mobilisation; I did not hear from any nursing staff but they are recorded as being very concerned about the pain he feels when being moved. These aggressive treatments will become more invasive, more burdensome and less tolerable as he deteriorates. He will be less conscious, more delirious during waking times, and less able to interact with his family. Such treatment would be futile and would prevent him from being able to spend his final time with his family in a peaceful setting away from the ICU. To prolong life would, in my judgment, exacerbate suffering.

Peel J approved the palliative treatment plan.

Comment

This case did not ultimately engage with the issues thrown up in the Townsend judgment, but is notable as the first reported case to have been brought before the Court of Protection specifically on the basis that the hospital had considered it was obliged to do so by the decision of the Court of Appeal.