FD25P00518 - [2025] EWHC 2247 (Fam)

Dr R is at a separate Trust. He has provided a detailed second opinion. He spent the morning with Baby J and staff on 24 August 2025. Of particular significance, he says:

“The severity and location of Baby J’s brain injury — notably involving the basal ganglia, thalami, and brainstem — are associated with very poor prognosis. In studies of neonatal HIE with similar patterns, around 89% of infants suffer death or severe neurodevelopmental impairment, and one cohort showed 95% had a grave outcome or died. Among survivors of severe HIE, up to 80% develop major disabilities, with the remainder often facing cognitive, motor, and behavioural impairments. These findings indicate an extremely poor prognosis, with no realistic prospect of neurological recovery or awareness.

Since repatriation to [X], Baby J’s condition has evolved. The acute brain swelling seen earlier has subsided, and he now demonstrates some weak spontaneous breathing above the ventilator. This means that if life-sustaining ventilation were withdrawn, he may continue to breathe for a variable period — ranging from hours to days — although sudden and early death remains possible. Importantly, any survival in this context would not be accompanied by awareness or quality of life, but would represent continued existence in a state of profound neurological injury.”

He gives the following detailed prognosis:

“Short-term: Baby J is capable of shallow spontaneous breathing, but this was observed with a breathing tube in situ, ensuring airway patency. On extubation, there is a significant risk that his airway will not remain protected. Given his profound hypotonia, absent gag reflex, and copious secretions, there is a high likelihood of airway obstruction (e.g. tongue falling back, pooling of secretions, or possible vocal cord palsy). This may result in apnoea and sudden death soon after withdrawal of ventilation.

Medium-term: If extubation is tolerated, survival could be variable in duration but would not represent neurological recovery. While some neuronal plasticity is theoretically possible in the developing brain, the extent and distribution of Baby J’s injury — affecting both cerebral hemispheres, basal ganglia, thalami, and brainstem — mean that there is no realistic possibility of meaningful recovery. He would remain profoundly impaired and entirely dependent.

Long-term: Survival would almost certainly be associated with profound neurological impairment, including severe spastic quadriplegic cerebral palsy, global developmental delay, epilepsy, and lifelong complete dependency. Any reflexive or brainstem-driven activity (e.g. gasping, hiccups, clonus) would not equate to awareness or purposeful interaction.”

He gives the clear view that: “Balancing these factors, it is my opinion that it is not in Baby J’s best interests for intensive life-sustaining treatment to be continued.” He also provides a conclusion that:

“In my independent expert opinion, the medical evidence is consistent and overwhelming: Baby J has sustained a catastrophic hypoxic–ischaemic brain injury, leaving him with no realistic prospect of meaningful recovery. The continuation of invasive intensive care would serve only to prolong his suffering. The course most consistent with his best interests is withdrawal of intensive care and provision of palliative comfort-focused support at [X], in the presence of his family.”

If Baby J were to survive the extubation, his evidence is that:

“…his care should remain firmly on a palliative pathway, led by the neonatal and children’s palliative care teams at [X]. This would allow him to remain close to his mother, who is herself critically unwell, and his wider family. Should he survive beyond the short term, care should transition to community paediatric palliative services and hospice support. If survival extends unexpectedly into months, referral to Child Development Services could be considered, though in view of the severity of his brain injury he would be expected to have profound, lifelong neurodisability, including severe cerebral palsy, epilepsy, intellectual impairment, and complete dependency.”

Dr R was a clear and confident witness. He said Baby J has no facial expression and he was not sure if he was in pain, although he accepted Baby J might have been in pain on 25 August. He agreed that ventilation is futile. He gave evidence that this is an extreme case and that the injury is profound. He did not see any hope of recovery. He said Baby J has a tiny bit of brain function but it will not transfer into functional ability. Furthermore, he noted that two weeks on from MRI, Baby J’s presentation has not recovered. He accepted it was likely that Baby J could not breathe independently and that continued treatment other than palliation was “unethical.”