England and Wales High Court (Family Division) Decisions

IN THE HIGH COURT OF JUSTICE
FAMILY DIVISION

		Royal Courts of Justice Strand, London, WC2A 2LL
		1 August 2014

1. MR JUSTICE MOYLAN: This is an emergency application brought by An NHS Trust. The application concerns B, a very young child who sustained injuries in an accident. B sustained severe burns to several parts of his body in an accident which was dealt with very expeditiously by his mother.
2. I am grateful to the NHS Trust for arranging for this hearing to take place at short notice. The Trust is represented by Mr Hallin. I am extremely grateful to B's parents for agreeing to participate in this hearing by telephone from their home. B's father has participated on behalf of them both.
3. The issue I have to decide is the form of treatment that B should receive, and in particular whether, if it is clinically required or indicated, B should receive a blood transfusion. For the purposes of determining the application I have read a witness statement provided by one of the medical team treating B, namely a consultant burns and plastic surgeon. B's father also gave evidence by telephone.
4. B's parents are both devout Jehovah's Witnesses and as a result of their faith they do not agree to and object to B being given blood transfusions. As B is a child, no one else can give consent for this treatment other than this court.
5. Given the urgent nature of this hearing and the form which it has taken, I propose to set out substantial parts of the consultant's statement. He is extremely experienced in caring for those who have sustained burns, having been a consultant for over 15 years. He is the consultant with responsibility for caring for B. He describes how B's burns are deep and says that:

"It is the unanimous view of the clinical team that the best practice treatment of B is skin grafting and that there is a significant risk that he will require a blood transfusion during this procedure."

Continuing with the consultant's evidence:

"A skin graft is when a healthy piece of skin is taken from one part of the body and placed over the burn area. Early surgical removal of the burned skin followed by skin grafting greatly reduces the risk of infection of the wound and facilities the healing of the burn site. It also reduces the likelihood and extent of the wound scarring."

He then describes how the skin grafting would take place and that the operation would be under general anaesthetic.

6. Dealing with the time frames, the consultant states that it is in B's best interests for skin grafts to be carried out no later than 7 to 10 days from the initial burn, namely before next Tuesday. There is a place available within the operating theatre timetable for B to receive a skin graft on Monday. He explains why the treatment has to be carried out quickly as follows:

"After seven to ten days from the initial burn there is a greater risk of bleeding during the skin graft procedure and for this reason if it is left for longer than seven to days it may be necessary to wait for a further period after which time the extent of bleeding during the procedure again becomes less. However, leaving it this long would not be appropriate for other reasons. Therefore, unless the skin graft is done urgently, it is much more likely that B will need a blood transfusion …

If the wound is left longer than seven to ten days, it will become increasingly contaminated, risking infection. All wounds are contaminated and the longer a wound is left, the more contaminated it becomes and the greater the risk of infection. A wound also becomes harder to treat the more contaminated it gets. If a skin graft is not undertaken within a seven to ten day window following the burn, there is a greater chance that the procedure will not be a success and a much greater risk of infection, including a risk of an infection developing after the procedure. If the skin graft gets infected, the graft can be lost altogether."

7. The consultant addresses the likelihood of B requiring a blood transfusion and says:

"In my clinical experience, if the skin graft in this case is performed within seven days of the burn, I estimate that there is a less than 10% chance that B would also need a blood transfusion. Whether a transfusion is needed during a skin graft depends upon the extent of the burn and the propensity of the patient to lose blood, which can be unpredictable. B's haemoglobin level is currently within normal limits and there is no reason to think he is presently at a particularly high risk of needing a blood transfusion. If the skin graft is not undertaken within seven days, the risk that B will need a blood transfusion becomes higher."

Because of the location of B's burns, a tourniquet cannot be used during the skin graft procedure. Adrenaline can be used and, it is with its use, that the chance of B requiring a transfusion is around 10%.

8. He then says:

"During a skin graft a patient will definitely lose blood as this cannot be completely avoided. However, we would only usually need to give a patient a blood transfusion should the haemoglobin levels fall to 80 grams per litre of blood or below. If a patient's haemoglobin levels fell to 80 grams and no transfusion were given I would be very concerned. It would be clinically necessary to provide a blood transfusion below 80 grams per litre of blood. I would deem a blood transfusion to be absolutely critical should the haemoglobin level fall below 60 grams per litre of blood."

9. The consultant next sets out the risks involved if a skin graft is undertaken without a blood transfusion:

"If the levels of haemoglobin drop below 80 grams per litre of blood during the graft procedure, which I consider possible but unlikely, then his condition will be serious; and if it fell to 60-40 grams per litre, which I consider very unlikely but still within the realms of possibility, there is a real risk of death should he not be given a blood transfusion. There is no alternative to a blood transfusion in this scenario - a blood transfusion must be given to avoid the real risk of death.

If B's levels of haemoglobin were to drop to between 60 and 80 grams he may well survive without a blood transfusion. However, he would subsequently be very unwell. He would be very weak, lethargic and would be very out of breath. He would also be much more prone to infection. The wound would be much less likely to heal and would break down. If the skin graft got infected, he would be at risk of developing sepsis. This would be life threatening and extremely traumatic. Ultimately and even with appropriate antibiotic treatment, sepsis can result in a protracted death."

10. In his evidence the consultant expresses the opinion that, in the event of a skin graft taking place without the ability to give a blood transfusion, there is a risk of death. The risk is lower in the event that the haemoglobin levels drop only to between 60 and 80 grams, but nevertheless there remains a risk of death as a result of the risk of sepsis developing. He also points to the significant benefits that would result from a transfusion taking place.
11. In conclusion the consultant says:

"I believe it clearly to be in B's best interests to receive a blood transfusion were his haemoglobin levels to drop below 80 grams. Although it is hoped that no transfusion will be required, we would need the option to do so as the consequences of not doing so if it is required could be serious and potentially fatal."

12. The consultant also deals with the risks that would flow from B having no skin graft at all. I do not propose to read these paragraphs into this judgment but the risks include the risk of infection and the resultant potential consequences if sepsis were to develop. Finally, he comments on the possibility of B requiring a second skin graft.
13. B's father, in very measured and compassionate terms, explained to me the position of himself and B's mother. He made clear, and I of course accept, that they love B dearly. They also want the best medical treatment for him. But, he explained, they are devout Jehovah's Witnesses and as a result they cannot accept blood being provided to B during the course of any operation or indeed under any circumstances because blood is sacred. They are raising B in the faith and cannot agree to and oppose treatment which includes the transfusion of blood.
14. When the father was speaking to me he raised two questions: whether there were, as he understood there were, alternatives to blood being provided during the course of the skin graft; and the risks for B of his receiving a blood transfusion.
15. Mr Hallin asked the consultant to give his opinion in answer to these two points. First, whether there are any alternatives to the use of blood or blood components if a transfusion is required? He replied that there are alternatives to liquids other than blood but there are no alternatives to blood being used if a transfusion of blood is required as a result of blood loss. Secondly, the risks which might result from B receiving a transfusion of blood? He described a number of risks. The first is a very small risk of an adverse reaction but he indicated that this can be ameliorated by cross-matching, which will take place in this case. A risk, which he described as negligible because of screening, of the blood itself having within it an infectious disease. Further, a chance of B reacting because of preservatives present in the blood.
16. The above summarises the evidence I have heard and on the basis of which I must make my decision.
17. In my view the evidence clearly establishes a small risk of death if B does not receive a blood transfusion, if required, during the course of either one or two skin graft operations. It is manifestly in B's best interests, as established by the evidence, that he receive a skin graft or skin grafts as may be required. It is also plain that it cannot be in B's best interests for him to be exposed to a risk of death if that can be avoided. In this case it can be avoided by his receiving a blood transfusion.
18. My decision must be determined by my assessment of what is in B's best interests because my paramount consideration is B's welfare. In reaching my decision, based on balancing all the factors bearing on the issue of B's welfare, I must weigh in that balance the wishes, opinions and views of B's parents. They alone have parental responsibility. But, as Ward LJ said in In re A (Children)(Conjoined Twins: Surgical Separation) [2001] Fam 147, although I must give "very great respect" to the parents' wishes, they are "subordinate to welfare": p. 193 A.
19. I do, of course, accord great respect to the views expressed by the father on behalf of himself and B's mother but, as referred to above, B's welfare is my paramount consideration. When judged against this overarching consideration, even a small risk of death is a risk which points powerfully towards the provision of available treatment subject to any counterbalancing risks consequent on such treatment.
20. In this case the proposed treatment is a blood transfusion or transfusions. It is not treatment which is wholly without risk, but the evidence establishes that the risks consequent on a blood transfusion are nothing like the nature of the risk to which B would be exposed if he were not to receive a blood transfusion. They are risks of a very different nature and magnitude to the risk consequent on B not receiving a blood transfusion, if such is clinically indicated, namely the risk of death.
21. Accordingly, and despite the deeply held views of B's parents, I am entirely satisfied that it is in B's best interests both for him to receive skin grafts and for him to receive blood transfusions if they are clinically indicated. The compelling need for the latter treatment to be available is in order to avoid the risks which would flow from his undergoing skin grafts without transfusions being available for him. I, therefore, make the order in the terms sought by the NHS Trust.
22. Finally, if I might repeat, I am extremely grateful to B's father for so clearly and calmly explaining to me the position held by himself and B's mother. I have no doubt at all that they love their son dearly. I also have no doubt that they object to the receipt by B of a blood transfusion because of their devout beliefs. I hope they will understand why I have reached the decision which I have, governed as it is by B's welfare.