NHS obtains emergency High Court Order to provide a life-saving blood transfusion to an 11-year old child.
We recently assisted an NHS Trust to obtain an emergency High Court Order to provide a blood transfusion to an 11-year old child. The parents and the child had refused to consent to the transfusion, due to their religious beliefs.
The emergency medical situation
The child presented to hospital with a new, severe anaemia. They were lethargic. Their haemoglobin (Hb) level was extremely low at 37mg/L, when the normal range for a child is between 115-155mg/L. This was the lowest Hb level that the consultant paediatrician had seen in a conscious child in 20 years. The doctors said that if the child did not receive a transfusion within the next six hours, there was a very high risk of sudden heart failure and death.
The legal situation
Although the child was articulate and could repeat their religious beliefs to refuse the transfusion, they could not voice the likely outcome of refusing blood. The doctors were of the view that the child was not Gillick competent to refuse the treatment. The parents indicated they were Jehovah's Witnesses and met with someone from the 'hospital liaison committee' from the JW community. The parents found themselves in the unimaginable position of being deeply concerned and worried for their child, but also having a deeply held religious belief that they could not consent to the blood transfusion.
The treating team had spent time trying to explore other treatment options, including in relation to bone marrow. Many Jehovah's Witnesses will accept fractions, which are derived from the primary blood components such as albumin, immunoglobulins, clotting factors etc. However, in this case the blood component that the child required was the red blood cells, which were refused.
As a result, the medical team did not have consent to provide the transfusion, and an emergency application to the High Court was required. The family understood, and appreciated the Trust taking this step.
The emergency telephone hearing
Given the emergency situation, the Court heard evidence later the same day from the family and the doctors by telephone. After a careful analysis of the child's best interests, the Order was agreed. The High Court Judge praised the way in which the family and the medical team had worked together; the family respected the Court's decision and the child received the blood transfusion that night.
Areas for learning for hospitals and doctors
- As soon as a JW child is admitted to
hospital, if blood is likely to be required, there should be
immediate exploration of possible treatment alternatives, but
always with a strong and persistent focus on what is best for the
child (if they are not competent to refuse). We recommend setting a
short deadline which is relevant to the risk to the child, so that
the exploratory stage does not drift.
In this case, the medical team had called for legal advice only on the third day after admission. They had found it difficult to make and voice a firm conclusion on the necessity for the blood transfusion. They were distracted by the fact that it was being refused, that the cause of the anaemia was not known and by the rarity of the situation (the consultant had not previous been in a similar situation). As a result, the team had continued to gently seek agreement, and a possible alternative treatment (which was not going to be effective within the required timeframe), without focussing on the need for an immediate resolution.
- The child's wishes and feelings should be explored immediately, and their Gillick competence assessed and recorded. Take note of repeated religious phrases, but ask about their meaning. Focus on asking the child questions, and letting them speak, to assess their understanding. Have an age-appropriate discussion about the specific risks and likely outcomes, but do not avoid asking about the hardest outcomes.
- Seek consent of the patient/parents to involve the hospital liaison committee to provide experienced support.
- Notify your legal team as soon as there is a suggestion that consent may not be provided. Before a court application can be made, you will need to discuss the situation with your lawyer, ensure all of the legal steps have been fulfilled, and provide written evidence in a witness statement on the specific situation, the proposed treatment, current test results, and the specific risks/benefits and likely timescales. It is likely to take the doctors at least two hours to gather all of the information and write the statement. There will also need to be detailed discussions with the family. Once an application is made, the Court will then allocate a hearing, based on your assessment of how urgent it is.
As a result of the transfusion, a catastrophic outcome was avoided for the child, which allowed time for the cause of the anaemia to be investigated.
Originally published 5 May, 2020
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