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Medical treatment cases

Note that this is a relatively new website category and most medical treatment cases can still be found in Category:Other capacity cases.
The old category structure used on this page is comprehensive as it contains every relevant case. The new database structure was introduced in 2019. It is more potentially useful than the old categorisation system: it includes all cases since January 2017, but only a minority of older cases: see Special:Drilldown/Cases. The pages below are initially ordered according to the dates on which they were added to the site (most recent first). The order can be changed by clicking on the symbol beside a column heading: click on the symbol beside "Page and summary" for alphabetical order; click beside "Categories" for the order in which the cases were reported. Click on the arrow symbol again to reverse the order. Click on a page name to view the relevant page. Asterisks mark those cases which have been added to the new database structure.

Case and summary Date added Categories
* Abortion S v Birmingham Women's And Children's NHS Trust [2022] EWCOP 10(1) The medical bodies' assertion that there had been "unanimous agreement" that S lacked capacity or that abortion was not in her best interests was a distortion of reality, as they had excluded S's objections from their decision making. Their failure to refer the matter to court, which was in contravention of Practice Guidance (Court of Protection: Serious Medical Treatment) [2020] EWCOP 2, meant that: (a) S, while a s3 patient and at the cost of incurring personal debt, had to bring proceedings herself; (b) there was extreme time pressure, the last day for a lawful abortion being the day after the hearing; and (c) the hearing inappropriately had to be held remotely and without the opportunity for public observation. (2) The relevant information in this particular case was: (a) what the termination procedures involve for S ("what it is"); (b) the effect of the termination procedure/the finality of the event ("what it does"); (c) the risks to S's physical and mental health in undergoing the termination procedure ("what it risks"); (d) the possibility of safeguarding measures in the event of a live birth. (3) S had capacity to decide whether to have an abortion. 2022‑03‑12 22:52:23 Judgment available on Bailii, Cases, 2022 cases, Medical treatment cases

* Litigation capacity, bulimia Lancashire and South Cumbria NHS Foundation Trust v Q [2022] EWCOP 6(1) The court-appointed expert had wrongly treated Mostyn J's decision in An NHS Trust v P [2021] EWCOP 27 (that it is virtually impossible and would be completely illogical to say that someone has litigation capacity despite lacking subject matter capacity in medical treatment cases) as meaning the two tests were synonymous, and had wrongly confused the likely unwise instructions with lack of capacity to instruct a legal adviser: Q had capacity to litigate. (2) The judge also disagreed with the expert on capacity in relation to potassium treatment for hypokalaemia (a consequence of bulimia) and found it difficult to resist the conclusion that the independent expert's instinctive professional desire to save Q's life had allowed the "tail of welfare to wag the dog of capacity" (for example, the expert's opinion was that Q attributed little value to her own life and saw little of value in her future, but this did not necessarily mean that her ability to weigh life and death medical decisions in the balance was impaired; instead, it might represent a finely calibrated utilitarian calculation). Q had capacity despite her decisions being unwise and most likely to hasten her death. (3) For essentially the same reasons, she had had capacity when when she made an advance decision to refuse treatment. 2022‑03‑03 23:14:18 Judgment available on Bailii

* Contingent declaration - caesarean North Middlesex University Hospital NHS Trust v SR [2021] EWCOP 58SR had capacity to make decisions about her care in pregnancy and at birth, and wanted a caesarean section. The judge did not determine whether a threshold test for contingent declarations was necessary but suggested (obiter) that the appropriate threshold would be "a real risk" that the person may lose capacity. There was such a risk, and it was in SR's best interests for a planned caesarean to take place, using force if necessary. 2021‑11‑13 21:39:11

* Dignity and CANH North West London CCG v GU [2021] EWCOP 59The judge considered various international texts, instruments and documents in relation to human dignity and, having decided that continued clinically-assisted nutrition and hydration was not in GU's best interests, was critical of the hospital for not arranging his death years sooner. Attention was drawn to Royal College of Physicians and British Medical Association, 'Clinically-assisted nutrition and hydration (CANH) and adults who lack the capacity to consent' (12/12/18) and the further guidance in Practice Guidance (Court of Protection: Serious Medical Treatment) [2020] EWCOP 2. 2021‑11‑13 21:07:10

* Caesarean section Dartford And Gravesham NHS Trust v SEB [2021] EWCOP 55In this out-of-hours application, made when SEB was already in labour, it was decided that she lacked capacity to litigate or to make decisions about her obstetric care, and that a caesarean section, together with any necessary restraint and deprivation of liberty, was in her best interests. 2021‑10‑19 20:52:28 Judgment available on Bailii, Cases, 2021 cases, Medical treatment cases

* Jehovah's Witness - validity of advance decision Re PW [2021] EWCOP 52A blood transfusion would change 80-year-old PW's outlook from being at risk at any time of sudden death to the possibility of living for another 5-10 years, but 20 years previously she had signed a proforma advance directive. The advance directive met the MCA requirements for an advance decision refusing life-sustaining treatment and was applicable to the proposed treatment. However, the Trust (supported by the PW's children but not the Official Solicitor) established on the balance of probabilities that it was not valid because she had "done [something] clearly inconsistent with the advance decision remaining [her] fixed decision" (s25(2)(c) MCA 2005): she had created an LPA and requested the removal of a DNR notice, both without mentioning her advance decision, and (when lacking capacity) had expressed wishes and feelings inconsistent with the advance decision. 2021‑09‑23 21:19:48

* Competence/capacity and puberty blockers Bell v Tavistock And Portman NHS Foundation Trust [2021] EWCA Civ 1363The Court of Appeal decided that the High Court should not have: (a) made a declaration about the relevant information that a child under 16 would have to understand, retain and weigh up in order to have the requisite competence in relation to puberty blockers; or (b) given its guidance on likely Gillick competence to give consent and, in relation to children and young people, on court involvement. The Court concluded that "applications to the court may well be appropriate in specific difficult cases, but it was not appropriate to give guidance as to when such circumstances might arise". 2021‑09‑17 20:05:36

* Serious medical treatment Cambridge University Hospitals NHS Foundation Trust v AH [2021] EWCOP 51AH was, in terms of the neurological impact and complications, "the most complex COVID patient in the world", and the central issue in the case was whether her ventilatory support should continue. 2021‑09‑04 21:15:03

* Caesarean - severe criticism of Trust University Hospitals Dorset NHS Foundation Trust v Miss K [2021] EWCOP 40(1) The application should have been made significantly earlier than the day before the proposed caesarean, and judicial criticism of delay felt like "a waste of breath" as it had been made so often. The Official Solicitor had been instructed the same day, and was unable to form a view on best interests, rendering her role effectively a "tick box exercise". (2) The Official Solicitor was "appalled" at the evidence of the consultant obstetrician, who decided that Miss K had capacity on 10/6/21 when she chose a caesarean on the basis that by giving birth sooner she could hold and keep safe her baby earlier, when in fact it had been decided on 20/5/21 that the local authority would take the baby so that when she woke up there would be no baby. (3) The court decided that a planned caesarean, Miss K having been taken from PICU to obstetric unit by force if necessary, was her best interests. In the event no force was necessary. 2021‑06‑19 13:59:53

* Non-treatment of anorexia A Midlands NHS Trust v RD [2021] EWCOP 35The Trust had decided not to treat RD's anorexia compulsorily under the MHA (even though that might, in the short term, prevent her death) and applied to the Court of Protection for legal protection. The court decided she lacked the relevant capacity and that further compulsory treatment was not in her best interests ("I am removing any threat of compulsion or compulsory admission to hospital under the Mental Health Act from RD"). The declarations were made under the inherent jurisdiction (as well as the MCA) since questions involving the MHA involve public law matters, in particular that doctors have to take into account the safety of the public. 2021‑05‑30 08:12:58

* Coronavirus vaccination SS v London Borough of Richmond upon Thames [2021] EWCOP 31(1) SS lacked capacity, owing to dementia, to decide whether to take a coronavirus vaccination, but consistently and volubly opposed it. (2) If she had capacity she should most likely would have refused: previously she had always attended to her medical welfare but resisted vaccinations. (3) It would not be in her best interests to persuade her by lying that her dead father had requested she take the vaccination. (4) It would not be in her best interests to administer it by force (sedation and restraint), as best interests requires evaluating welfare in a sense broader than merely epidemiological: SS would look to the carers to help, and they would not be able to intervene, which likely would dismantle the tentative trust that had been established over the months. 2021‑05‑23 14:20:18

* Agoraphobia and pregnancy A NHS Foundation Trust v An Expectant Mother [2021] EWCOP 33The expectant mother's severe agoraphobia meant she might not be able to travel to hospital even if that became medically necessary. The court decided that: (1) she lacked capacity to make decisions about the location of the delivery of her baby; (2) it was in her best interests to be taken to hospital for a planned delivery, using force and involving deprivation of liberty if necessary; (3) she had capacity to choose between induced labour and Caesarean section, and between local and general anaesthetic. 2021‑05‑21 19:49:53

* Anorexia A Mental Health Trust v ER [2021] EWCOP 32(1) The parties agreed that ER lacked capacity to make decisions about her anorexia or the litigation, and the judge, having explored her doubts in detail, ultimately came to the same view. (2) It was not in ER's best interests to be forced to accept treatment or inpatient admission, given her renal failure and extreme dislike of eating disorder units and psychiatric hospitals. (3) More support in the community, in particular moving to a supported living placement where she could have dialysis and more support and company, would be in her best interests, and the local authority and CCG were joined as parties and directed to give evidence of proposals for extra support. 2021‑05‑21 10:53:02

* Compulsory caesarean X NHS Foundation Trust v Ms A [2021] EWCOP 17The court decided that Ms A lacked capacity to conduct proceedings or to make decisions regarding birth (she wanted a vaginal birth), obstetric care and post-operative management, and that it was in her best interests to be transferred to another hospital for an elective caesarean section, or to receive an emergency caesarean section if necessary before then, using force if necessary. 2021‑04‑14 20:10:33

* Compulsory admission for caesarean East Lancashire Hospitals NHS Trust v GH [2021] EWCOP 18At an out-of-hours hearing the Court of Protection declared that GH, having gone into labour at home and suffered an obstructed labour, by reason of her acute agoraphobia and anxiety lacked capacity to decide whether to agree to be admitted to hospital for obstetric treatment and a possible emergency caesarean section, and that it was in her best interests to be conveyed from her home to hospital for treatment by ambulance, forcibly if necessary. In the end she gave birth to a healthy baby boy at home before the court decision could be implemented. 2021‑04‑14 20:00:55

* Parental consent for puberty blockers AB v CD [2021] EWHC 741 (Fam)The two issues in this case (an application by XY's mother that she and the father have the ability in law to consent on behalf of XY to the administration of hormone treatment to suppress puberty) were: (1) Do the parents retain the legal ability to consent to the treatment? (2) Does the administration of puberty blockers fall into a "special category" of medical treatment by which either: (a) an application must be made to the Court before they can be prescribed? (b) as a matter of good practice an application should be made to the Court? 2021‑04‑11 21:19:47

* Death following suicide attempt Re Lilia: A London Trust v CD [2021] EWCOP 23Lilia was in a vegetative state following an unsuccessful suicide attempt on a psychiatric ward. The Trust's clinical treating team argued that continuing treatment was futile and could be unethical. Lilia's mother and sister agreed for treatment to end, but her father argued that she would want to live and that it was too early to end her life given the remote possibility of neurological change that could place her in a minimally conscious state minus. The judge concluded that it was not in Lilia's best interests to administer life-sustaining medical treatment. 2021‑04‑07 20:40:38

* Death - child NHS Trust v Parents and S [2021] EWHC 594 (Fam)Five options for the treatment of a 9-month-old baby were presented to the court: (1) continuing the current regime; (2) continuing with intensive ventilation and support care but not escalating treatment if he deteriorates further; (3) extubating him but re-intubating him if he cannot manage; (4) extubating him and giving him Vapotherm or continuous positive airway pressure (CPAP) if he cannot manage, rather than re-intubating him; (5) withdrawing life sustaining treatment and giving palliative care. His parents argued for option 2. The Trust and Children's Guardian argued for option 5, and the judge decided that this would be in his best interests: "I understand and respect the parents' views, including their religious views (which no doubt S would share) but it is not in his best interests to put him through so much simply to keep him alive even if he is able to experience some comfort from being looked after by his parents. If he were able to express any wishes about this it is difficult to believe he would choose this sort of existence for himself." 2021‑03‑19 22:18:16

* Medical treatment and children Re X (A Child): Barking, Havering and Redbridge University Hospitals NHS Trust v X [2020] EWHC 1630 (Fam)Neither X, a 15-year-old Jehovah's Witness, nor her mother would consent to urgent treatment by way of blood transfusion, though neither would resist if the court ordered it. Noting that "the court, in suitable circumstances, has the jurisdiction to override the decisions and wishes of a Gillick competent child where it is in the child's best interests for it to do so", the blood transfusion was declared to be in her best interests. 2021‑02‑27 08:12:13

* Death University Hospitals of Leicester NHS Trust v NZ [2021] EWCOP 16NZ was receiving life-sustaining treatment by way of an extracorporeal membrane oxygenation machine (ECMO), a last-resort treatment which had increased by a third during the coronavirus pandemic. The clinical lead consultant for ECMO stated that rather than seeking to preserve her life he was now "prolonging her death", and signalled to the judge that further treatment would be professionally unethical. The judge stated that best interests "requires the broad canvas of NZ's life, circumstances and needs to be considered in their totality" (not just medical opinion, religious beliefs, or wishes and feelings) and that "a court will never seek to compel or encourage a medical professional to act in a way that he or she considers unethical", and concluded that the treatment was not in her best interests. 2021‑02‑26 21:54:20

* Death following stroke Sandwell and West Birmingham Hospitals NHS Trust v TW [2021] EWCOP 13(1) TW suffered catastrophic brain injury, arising from a stroke, which meant he lacked the capacity to decide whether to continue to receive life-sustaining treatment. (2) The continuation of ventilatory support and likely invasive treatment could no longer be reconciled with his best interests. (3) His three daughters wished to travel from Canada to be with him at the very end of his life and be present, if possible, when he died, a journey which owing to coronavirus restrictions would take over three weeks to arrange. The medical evidence was that the likely treatment "comes perilously close to, if not crossing, an ethical boundary" and the judge decided that any plan artificially to sustain his situation during this period would not be in his best interests. 2021‑02‑17 23:21:25

* Cancer treatment Newcastle upon Tyne Hospitals NHS Foundation Trust v RB [2021] EWCOP 11RB lacked capacity to make decisions regarding his treatment. During the course of the hearing his litigation friend came to the view that the form of cancer care set out by the Trust was in RB's best interests. The matter was therefore agreed, but the court gave a short judgment. 2021‑02‑12 22:39:13

* Medical treatment and children Re X (A Child) (No 2): An NHS Trust v X [2021] EWHC 65 (Fam)The applicant, a Jehovah's Witness child refusing blood transfusions, unsuccessfully challenged the conventional wisdom that the court can in an appropriate case overrule the consent or refusal of medical or surgical treatment given by a person who has not yet reached the age of 18. 2021‑02‑07 23:19:58

* Leg amputation Pennine Acute Hospitals NHS Trust v TM [2021] EWCOP 8(1) TM lacked capacity in relation to the proposed bilateral below-knee amputation. (2) It was in his best interests to receive the surgery, and quickly, to avoid sepsis and death. (3) The pervasiveness of his misguided belief that he would recover without surgery substantially diminished the weight that might otherwise be given to his consistently expressed refusal. (4) The judge noted that it had become much easier for judges to visit the protected party since video conferencing platforms had been adopted. 2021‑01‑30 22:07:29 2021 cases, Cases, Judgment available on Bailii, Medical treatment cases

* Death and religion JB v University Hospitals Plymouth NHS Trust [2020] EWCA Civ 1772The COP had decided that it was in RS's best interests not to receive life-sustaining treatment, including artificial ventilation, nutrition and fluids. On appeal, his niece argued that the decision was unjust because of serious procedural error in that it was taken with an insufficient degree of inquiry into how RS would have wanted to be treated against the backdrop of the tenets of his Roman Catholic faith (and also that the judge breached natural justice and Article 6 by prohibiting cross-examination of RS's wife on the grounds that she was distressed and/or by permitting her to communicate additional evidence by a confidential letter to the judge which was not disclosed to the parties). Permission to appeal was not granted. 2020‑12‑28 21:42:58

* Competence/capacity and puberty blockers Bell v Tavistock And Portman NHS Foundation Trust [2020] EWHC 3274 (Admin)(1) The relevant information that a child would have to understand, retain and weigh up in order to have the requisite competence in relation to puberty blockers, would be as follows: (i) the immediate consequences of the treatment in physical and psychological terms; (ii) the fact that the vast majority of patients taking puberty blockers go on to cross-sex hormones and therefore that he or she is on a pathway to much greater medical interventions; (iii) the relationship between taking cross-sex hormones and subsequent surgery, with the implications of such surgery; (iv) the fact that cross-sex hormones may well lead to a loss of fertility; (v) the impact of cross-sex hormones on sexual function; (vi) the impact that taking this step on this treatment pathway may have on future and life-long relationships; (vii) the unknown physical consequences of taking PBs; and (viii) the fact that the evidence base for this treatment is as yet highly uncertain. (2) Gillick competence is treatment- and person-specific but the court gave clear guidance that it is highly unlikely that a child aged 13 or under, and very doubtful that a child aged 14 or 15, would ever be Gillick competent to give consent to being treated with puberty blockers. (3) There is a presumption that young people aged 16 or over have capacity to consent but, given the long-term and potentially irreversible consequences and the experimental nature of the treatment, clinicians may well consider that it is not appropriate to move to treatment such as puberty blockers or cross-sex hormones without the involvement of the court, and it would be appropriate to involve the court when there may be any doubt about long-term best interests. 2020‑12‑03 22:16:30 ICLR summary

* Treatment despite religious delusions Sherwood Forest Hospitals NHS Foundation Trust v C [2020] EWCOP 10(1) Having previously undergone two hysteroscopies, and initially consented to removal of her ovaries and fallopian tubes, C disengaged, expressed religious views (such as that only God could cure her cancer), and was assessed as lacking capacity. The judge decided that "she clearly lacked capacity and her rejection of the treatment, which is clinically so manifestly in her best interests, is predicated on a delusional belief structure which manifests itself in the language of religion". (2) The delay in this case, which was attributable to the treating clinicians not initially knowing C had paranoid schizophrenia, and their reluctance to contemplate coercion, should not have happened and likely stressed C and her family, but had not led to neglect of the cancer. 2020‑07‑06 13:47:32

* Capacity and nutrition/hydration QJ v A Local Authority [2020] EWCOP 7QJ had capacity to decide about nutrition and hydration despite his reluctance to answer certain questions. He was in agreement with the care plan, which included (a) Fortisip; (b) weighing; (c) discharge to a care home; (d) no readmission to hospital if he refuses to accept food or water. 2020‑07‑03 15:34:04

* Medical treatment Sherwood Forest Hospitals NHS Foundation Trust v H [2020] EWCOP 6In the previous judgment the court had authorised surgical excision of a squamous cell carcinoma on Mrs H's left cheek. By the surgery date its further growth rendered it inoperable. Other treatments, including electro-chemo therapy and palliative radiotherapy under general anaesthetic were under consideration, with a view to putting together a care plan for Mrs H's needs for the remainder of her life. The court would review the care plan because (a) the history of the case required that it be monitored, and (b) Mrs H's daughter had requested this. 2020‑07‑03 14:58:09

* Medical treatment delay Sherwood Forest Hospitals NHS Foundation Trust v H [2020] EWCOP 5Noting that the delay in bringing the case to court "may mean that a life is lost that could well have been saved", the judge authorised surgical excision under general anaesthetic of a squamous cell carcinoma on Mrs H's left cheek. 2020‑07‑03 14:39:07

* Finely-balanced treatment decision QJ v A Local Authority [2020] EWCOP 3(1) This s21A appeal was adjourned for medical evidence in relation to whether QJ had capacity (a) to decide on whether to receive nutrition and hydration either orally or artificially; (b) to decide more generally on medical treatment; and (c) to decide on admission to hospital. (2) On the day of the hearing QJ had for the first time indicated a willingness to be put on a drip. Even if QJ were now found to have capacity, the case should still come back before the court because: (a) it may very well be a "finely balanced" decision (and so within Practice Guidance (Court of Protection: Serious Medical Treatment) [2020] EWCOP 2); and, in any event, (b) where there is already an application in relation to the central issue the matter should only be concluded within court proceedings and not left to clinical decisions. 2020‑07‑03 13:46:57

* Serious medical treatment guidance Practice Guidance (Court of Protection: Serious Medical Treatment) [2020] EWCOP 2"This practice guidance sets out the procedure to be followed where a decision relating to medical treatment arises and where thought requires to be given to bringing an application before the Court of Protection. The procedure is currently being reviewed within the revised MCA Code. That will, in due course, be subject to public consultation and Parliamentary scrutiny. This guidance is intended to operate until such time as it is superseded by the revised Code." 2020‑07‑03 10:25:21 2020 cases, Cases, ICLR summary, Judgment available on Bailii, Medical treatment cases

* Withholding life-sustaining treatment from baby Rotherham Metropolitan Borough Council v ZZ [2020] EWHC 185 (Fam)"It is impossible not to feel that X's life is one of nothing but suffering. As is set out in the cases above, life itself is precious and there is a very strong presumption in favour of preserving life. But X's life is a truly tragic one and certainly reaches a threshold of intolerability. ... His life expectancy is probably no more than a year on the basis of the literature. ... For all these reasons I am clear that it is not in X's best interests that he should be resuscitated or that he should be given life sustaining treatment." 2020‑04‑02 14:48:15 2020 cases, Cases, Judgment available on Bailii, Medical treatment cases

* Force feeding under s63 MHA 1983 JK v A Local Health Board [2019] EWHC 67 (Fam)"In my view his refusal to contemplate any alternative paths, and his rigid belief that refusing to eat is his only way forward, is a consequence of his autism and as such falls within s.63. The proposed force feeding is therefore certainly capable of being treatment for the manifestation of his mental disorder. However, that does not mean that I by any means accept that force feeding JK would be in his best interests, or critically would be "treatment" that falls within the definition in s.145(4) of the MHA, as being "to alleviate or prevent a worsening of the disorder…". It is apparent that force feeding is a highly intrusive process, which involves sedating the patient whilst the naso-gastric tube is inserted and potentially having to restrain the patient for fairly prolonged periods. This process would be extremely upsetting for any patient, but for JK with his ASD and his aversion to eating in front of other people, the process would be even more traumatic. JK said in oral evidence that he viewed the possibility as abhorrent, and it was clear from that response how incredibly upsetting for all concerned having to go through that process would be. If it came to that stage close consideration would necessarily have to be given to the terms of article 3 ECHR and the caselaw such as Herczegfalvy v Austria [1993] 15 EHRR 437 and the test of medical necessity." 2020‑03‑13 11:40:52 2019 cases, Cases, Judgment available on Bailii, Medical treatment cases

* Haemodialysis under s63 MHA 1983 A Healthcare and B NHS Trust v CC [2020] EWHC 574 (Fam)"By reason of the above, the Court finds that: (i) The physical condition CC is now in, by which dialysis is critical to keep him alive, is properly described as a manifestation of his mental disorder. There is a very real prospect that if he [were] not mentally ill he would self-care in a way that would have not led to the need for dialysis. Further, CC's refusal of dialysis is very obviously a manifestation of his mental disorder and dialysis treatment is therefore treatment within the scope of section 63 MHA 1983. (ii) CC's capacity to consent to dialysis treatment fluctuates, however his consent is not required in order to be treated, by way of dialysis treatment, under section 63 MHA 1983. (iii) The decision whether it is in CC's best interests to receive dialysis treatment is a matter for CC's responsible clinician (having consulted clinicians attending to his physical health, including the consultant nephrologist), subject to the supervisory jurisdiction of the Court. (iv) Section 58 has no applicability. Section 62 disapplies section 58 in urgent treatment cases such as this where treatment is immediately necessary to save CC's life, to prevent a serious deterioration of his condition, and to alleviate serious suffering. Section 63 is the appropriate course. (v) As section 63 MHA 1983 can be used as authority to provide medical treatment to CC, including by dialysis treatment and by the use of light physical restraint and chemical restraint (if required), it is unnecessary for the court to exercise its discretion and make a contingent declaration pursuant to section 15(1)(c) MCA 2005 that it is lawful to treat CC in accordance with the proposed dialysis treatment plan in the event that he lacks capacity to make a decision regarding dialysis treatment at the relevant time." 2020‑03‑13 11:34:20 2020 cases, Cases, Judgment available on Bailii, Medical treatment cases

* Dental treatment - delay Cardiff and Vale University Health Board v P [2020] EWCOP 8"It might seem, from the above account, that some dental assessment was required quickly and now as long ago as November or early December 2019. Plainly, it was. But the application was only made by the Health Board on 20th February 2020. The proposed inspection and/or treatment is not to take place until early March. For anybody who has had toothache, even delay between now and then looks like an eternity. But this young man, it seems, has been suffering, and significantly so, for nearly five months. This is little short of an outrage. It is indefensible. ... An additional complication arose in November when P was taken to the local A&E by his parents with an obvious bruise to his forehead. They believed that his behaviour was so markedly changed that they feared he had some sort of concussion and may have fractured his skull. It is, to my mind, self-evident that there was an urgent medical emergency that should have been investigated within hours or days, but in fact there has, as yet, been no CT scan at all. ... It is, sadly, yet again, a situation in which there has been a fundamental failure to communicate effectively by those responsible for P's care. This message has now been the conclusion of so many reviews, including serious case reviews, that it has become almost trite. There is no point identifying lessons to be learned if they are not, in fact, learned." 2020‑02‑27 23:29:00 2020 cases, Cases, Judgment available on Bailii, Medical treatment cases

* Abortion Re AB (Termination of Pregnancy) [2019] EWCA Civ 1215"The requirement is for the court to consider both wishes and feelings. The judge placed emphasis on the fact that AB's wishes were not clear and were not clearly expressed. She was entitled to do that but the fact remains that AB's feelings were, as for any person, learning disabled or not, uniquely her own and are not open to the same critique based upon cognitive or expressive ability. AB's feelings were important and should have been factored into the balancing exercise alongside consideration of her wishes. ... [I]n my judgement, she clearly gave inadequate weight to the non-medical factors in the case, while the views expressed by the doctors were necessarily significantly predicated upon imponderables. In the end, the evidence taken as a whole was simply not sufficient to justify the profound invasion of AB's rights represented by the non-consensual termination of this advanced pregnancy." 2020‑02‑25 11:10:15 2019 cases, Cases, ICLR summary, Judgment available on Bailii, Medical treatment cases

* Abortion An NHS Foundation Trust v AB [2019] EWCOP 26"This is an application by the NHS Trust for an order in respect of a 24 year old woman AB who is 22 weeks pregnant and, who the Trust say lacks capacity and in whose best interests it is said to have a termination of pregnancy. ... I would like to record my unhappiness about the lateness of this application. AB is now estimated to be 22 weeks pregnant and therefore the cut-off date under the Abortion Act 1967 of 24 weeks is imminent. ... I am acutely conscious of the fact that for the state to order someone to have a termination, where it appears that they do not want it, is immensely intrusive and certainly interferes with her Article 8 rights. ... In my view the balance in terms of AB's best interests lies in her having the termination." 2020‑02‑25 10:55:18 2019 cases, Cases, Judgment available on Bailii, Medical treatment cases

* Contingent/anticipatory declarations - MCA/inherent jurisdiction - Caesarean section Guy's and St Thomas' NHS Foundation Trust v R [2020] EWCOP 4R had capacity to make decisions as to her ante-natal and obstetric care but there was a risk that she would lose capacity during labour and refuse a Caesarean section. (1) MCA 2005 s16 (Powers to make decisions and appoint deputies: general) applies only to those who currently lack capacity. (2) MCA 2005 s15 (Power to make declarations) is not so limited and so can authorise contingent declarations. (3) Deprivation of liberty cannot be authorised by s15 but the inherent jurisdiction may be utilised to fill that lacuna which would otherwise render the s15 power nugatory. 2020‑01‑30 18:54:37

* Withdrawal of life-sustaining treatment - transfer to Italy Raqeeb v Barts NHS Foundation Trust [2019] EWHC 2531 (Admin)This judgment related to: (a) the child's (Tafida's) judicial review of the Trust's decision not to agree to transfer her to an Italian hospital; (b) the Trust's application for a specific issue order under s8 Children Act 1989, and for an inherent jurisdiction declaration, that it was in the child's best interests for life-sustaining treatment to be withdrawn. Both applications were dismissed, with the effect that one of the hospitals had to continue life-sustaining treatment and, there being no justification for interfering with Tafida's right (under Article 56 Treaty for the Functioning of the European Union) to receive treatment in another EU state, it was anticipated that the transfer would take place. The judgment provides guidance on dealing with a request by parents of an EU citizen child for transfer for medical treatment in another Member State. 2019‑10‑17 22:42:09

* Pregnancy - OS out-of-hours representation Guy's and St Thomas' NHS Foundation Trust v X [2019] EWCOP 35(1) Official Solicitor's lack of out-of-hours service: "... I invite the Official Solicitor to urgently review this position and consider putting in place arrangements that will ensure appropriate representation out of normal court hours for those individuals who are the subject of urgent applications that potentially involve serious medical treatment. ... [E]very effort must be made to issue such applications during normal court hours." (2) Pregnancy: "Having considered the submissions of the parties there is, in my judgment, in accordance with s 48 Mental Capacity Act 2005, reason to believe that X lacks capacity in relation to the matter, namely the medical intervention that may be necessary for X to give birth to a baby who is safe and well. On the evidence the court has from Dr Y, which I accept, his assessment is X is unable to reconcile her conflicting beliefs (on the one hand of wanting a natural birth and also wanting a live, well and safely born baby) in a way that she is able to balance the pros and cons. Additionally, there is, in my judgment, a real risk the position is unlikely to change and is more likely to deteriorate. He concluded X showed limited insight in relation to her previous mental ill- health. I have carefully considered the submissions on behalf of the Official Solicitor regarding capacity but looking at all the evidence and information available to the court I am satisfied the interim declaration should be made." 2019‑08‑19 23:28:47 2019 cases, Cases, Judgment available on Bailii, Litigation friend cases, Medical treatment cases

* Serious medical treatment - delay in making application Royal Bournemouth and Christchurch Hospitals NHSFT v SE [2018] EWCOP 45"Whilst, of course, it is understood emergencies do arise, in this case the emergency was due to the failure to have any effective system in place for securing legal advice for clinicians in the Trusts. I hope that the procedures now put in place (as set out at the end of this judgment) will be replicated elsewhere to avoid this situation happening again. ... [H]er best interests will be met by this court endorsing the Order that has been agreed and giving the applicants permission to be able to carry out the procedures set out in paragraph 4, namely the amputation of her right leg ... 2019‑08‑10 22:27:25 2018 cases, Cases, Judgment available on Bailii, Medical treatment cases

* Death - wishes and feelings Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust v TG [2019] EWCOP 21"I am being asked to take today an irreversible decision that will lead inevitably to death sooner rather than later and probably within minutes or seconds of the tube being removed. I am being asked to do so in the face of what I find are the wishes and feelings of TG. ... I have come to the clear decision that it is in the patient's best interests that intubation should continue. I recognise that this places a huge burden on the treating team. It is against their advice and their wishes and of course also those of Dr Newman but I remind myself constantly, this is her life and her wishes as I have found them to be and nobody else's. It may be that if the position were to remain the same in six months' time or no successful tracheostomy had been carried out that different considerations might apply but I am not looking at the future, I am looking at things as they are now and for those reasons I reach my decision and refuse the application." 2019‑07‑08 22:29:31 2019 cases, Cases, Judgment available on Bailii, Medical treatment cases

* Jehovah's Witness - blood transfusion Manchester University NHS Foundation Trust v DE [2019] EWCOP 19"The only issue during the hearing was the degree to which DE's wishes and feelings would be overborne by a decision to allow a blood transfusion, in the light of her being a Jehovah's Witness; and therefore whether there was a disproportionate interference in DE's article 8 rights. However, the evidence even at the oral hearing was that although DE described herself as a Jehovah's Witness she was not someone for whom those beliefs were central to her personality or sense of identity. During the oral hearing I did not get any sense that she would feel deeply upset if an order was made in the form sought, or that she would feel a deep conflict with her religious beliefs. As such she was someone who was in a quite different decision from B in Jackson J's decision, where his religious beliefs were fundamental to B's sense of who he was. The other stark contrast with that case is that DE had been completely clear that she did not want to die. She is also significantly younger than was B." 2019‑07‑08 22:16:16 2019 cases, Cases, Medical treatment cases, Judgment available on Bailii

* Withdrawal of CANH A Clinical Commissioning Group v P [2019] EWCOP 18"Having given anxious consideration to this very sad case, and with profound regret, for the reasons set out above I am satisfied this court should declare that P lacks capacity to make decisions regarding CANH. Further, in circumstances where I have concluded that P lacks capacity to decide for herself whether or not to continue to receive CANH, I am satisfied that it is in P's best interests to consent on her behalf to the withdrawal of that treatment, a step that I acknowledge will result in her death. ... In all the circumstances, I am satisfied that the sanctity of P's life should now give way to what I am satisfied was her settled view on the decision before the court prior to the fateful day of her overdose in April 2014." 2019‑05‑29 21:45:45 2019 cases, Cases, Judgment available on Bailii, Medical treatment cases

* HBSO, colonoscopy, deception University Hospitals of Derby and Burton NHSFT v J [2019] EWCOP 16"[Anne] is the subject of an application brought by the [Trust] for declarations that it is in Anne's best interests to undergo a hysterectomy and bilateral salpingo-oophorectomy and a colonoscopy, and that, in order to enable those to be undertaken, it is in her best interests for a transfer plan to be implemented which will involve her sedation and a level of deception to ensure her presence at hospital for the procedures to be undertaken. The application arises because it is said that Anne lacks capacity. ... It is entirely right that cases such as this, where medical decisions and the plan for their implementation impact so profoundly on P's personal autonomy, bodily integrity and reproductive rights, should be considered by the Court of Protection at High Court level, and as this case demonstrates, once in the hands of the court and the Official Solicitor they can be dealt with rapidly. I therefore have no hesitation in declaring that it is in Anne's best interests to undergo HBSO and colonoscopy (and associated surgical procedures) and for the care plan to be implemented in its final amended form." 2019‑05‑10 21:41:37 2019 cases, Cases, Judgment available on Bailii, Medical treatment cases

* Amputation East Lancashire Hospitals NHS Trust v PW [2019] EWCOP 10"This is an application by East Lancashire NHS Trust for orders under the Mental Capacity Act 2005 that PW lacks capacity "to make a decision regarding whether to undergo the leg amputation surgery to address his high risk of sepsis"; and that it is lawful to carry out that surgery having regard to his best interests. Before dealing with the substantive issues in this case I will deal with the timing of the application." 2019‑04‑19 22:41:55 2019 cases, Cases, Judgment available on Bailii, Medical treatment cases

* Withdrawal of CANH; advance decision NHS Cumbria CCG v Rushton [2018] EWCOP 41"This is an application regarding the proposed withdrawal of clinically assisted nutrition and hydration in respect of Mrs Jillian Rushton, who is now 85 years of age. Since sustaining a traumatic head injury in December 2015, Mrs Rushton has suffered from a prolonged period of disorder of consciousness. Insofar as a label is relevant, the consensus of medical opinion, in respect of which there is no dissent at all, is that she is in a persistent vegetative state (PVS). In their recent guidance, ‘Clinically-assisted nutrition and hydration (CANH) and adults who lack the capacity to consent’, the Royal College of Physicians and the British Medical Association have noted that the importance of obtaining a precise and definitive diagnosis has reduced. It is recognised by the Courts and clinicians that drawing a firm distinction between vegetative state and minimally conscious state is frequently both artificial and unnecessary. In practice, when assessing best interests, information about the patient’s current condition and prognosis for functional recovery and the level of confidence with which these can be evaluated is invariably of greater importance than a precise diagnosis. ... It perhaps requires to be said, though in my view it should be regarded as axiomatic, that the medical profession must give these advanced decisions the utmost care, attention and scrutiny. I am confident the profession does but I regret to say that I do not think sufficient care and scrutiny took place here. The lesson is an obvious one and needs no amplification. Where advanced decisions have been drawn up and placed with GP records there is an onerous burden on the GP to ensure, wherever possible, that they are made available to clinicians in hospital. By this I mean a copy of the decision should be made available and placed within the hospital records with the objective that the document should follow the patient. It need hardly be said that it will rarely, if ever, be sufficient to summarise an advance decision in a telephone conversation. ... The family have ... made it clear to me that she would not have regarded her present situation as tolerable. Whilst I have no doubt that she would understand the commitment of her son, Tim and his profound resistance to letting her go, I have equally no doubt that she would want to be let go and I have no hesitation in concluding that it is my responsibility to respect this." 2019‑04‑05 21:53:04 2018 cases, Advance decision cases, Cases, Judgment available on Bailii, Medical treatment cases

* Withdrawal of CANH SS v CCG [2018] EWCOP 40"The application seeks a declaration pursuant to section 15 (that it is lawful and in B's best interests for CANH to be withdrawn) and, secondly, an order pursuant to section 16 for such withdrawal and for B to receive palliative care only. If granted, it is anticipated that B will pass away. ... In support of granting the application there are a number of important factors. It is consistent with her previously expressed feelings and wishes. It supports her right, I suspect strongly held, to self-determination. She has no quality of life. Therapeutically, her life is futile, there is no hope of recovery. There is no hope. If I allow the application and make the declarations, it will bring to an end the invasive and, in my judgment, burdensome medical treatment from which she, B, obtains no benefit. It is consistent with her Muslim religion. It is consistent with her devoted husband's views of his wife's best interests. It is consistent with the unanimous views of those that are responsible for caring and treating her, whether it be the clinical or the support team. Is there any factor which weighs in the scales against granting the application? There is. It is the powerful principle that if I make the declarations, it will inevitably lead to B's death, so offends against the very strong principle of the sanctity of life. Having taken time to consider the matter, it seems to me clear that the direction of travel is all one way. It is with my very greatest sympathy to the family and B's husband in particular that balance falls very clearly in favour of me granting the application and making the declarations as sought, and I do so." 2019‑03‑20 21:43:32 2018 cases, Cases, Judgment available offline, Judgment missing from Bailii, Medical treatment cases

* Retrospective authorisation of DNA swab sample DCC v NLH [2019] EWCOP 9"I concluded it would be appropriate to make a declaration (1) that NLH lacked capacity (a) to make decisions as to the provision of buccal swab samples, the testing of such samples and the profiling of his DNA and (b) to conduct these proceedings, and further (2) that it was lawful for the local authority to arrange for the taking of buccal swabs from NLH for the purposes of performing DNA paternity testing in respect of the child. I further concluded it would be appropriate to make an order, by consent, that the court consented on NLH's behalf for the swab sample to be taken and tested and so that his DNA could be profiled to establish whether he was the father of the child. Shortly before the order was made, however, it emerged that a member of staff from the DNA testing company, Lextox, had already attended at the nursing home and taken the sample, with the agreement of NLH's family, but without either the formal consent of NLH (who lack capacity to provide consent) or the approval of the court. ... I therefore agreed to prepare this short judgment to remind practitioners, carers and those involved in taking samples in these circumstances that, where the patient lacks capacity and an application has been made to the Court of Protection for an order authorising the taking of a sample, it will be unlawful for the sample to be taken without the Court's permission. All practitioners and professionals working in this field ought to be aware that there is always a judge of the Family Division on duty available to sit in the Court of Protection twenty-four hours a day, seven days a week, every day of the year, to deal with urgent applications, usually by telephone. Consequently, there is no excuse for any failure to comply with the obligations to obtain the court's permission in circumstances such as these. As stated, no harm arose on this occasion, but any infringement in future will run the risk not only of attracting severe criticism from the Court but also potentially incurring liability for damages if a breach of human rights were to be established." 2019‑03‑20 20:45:21 2019 cases, Cases, Judgment available on Bailii, Medical treatment cases

* Medical treatment case King's College Hospital NHS Foundation Trust v FG [2019] EWCOP 7"[T]he King's College Hospital NHS Foundation Trust seeks an order in the following terms in relation to FG: (a) a declaration that FG lacks capacity to make decisions regarding the medical treatment for his physical health conditions; (b) that it is lawful and in FG's best interests for him to undergo an operation to repair his right shoulder fracture/dislocation; and (c) that it is in his best interests to receive any sedation and anaesthesia his clinicians think necessary to allow the operation to be done. The matter has come in front of me today as urgent applications judge." 2019‑03‑15 21:01:36 2019 cases, Cases, Deprivation of liberty, Judgment available on Bailii, Medical treatment cases

* Medical treatment, including CPR University Hospitals Birmingham NHSFT v HB [2018] EWCOP 39"When considering what is in HB's best interests, I take account of the fact that the balance of medical evidence would support the view that the treatment set out in the second part of the treatment plan would bring about no significant improvement in HB's underlying condition and, to that end, they might be seen as futile. ... Against that, I have to balance the very clear wishes, expressed by HB to her daughter, that she would want all steps taken to preserve her life ... Where it is not clear whether HB will make an improvement in her neurological condition, it is, in my judgment, contrary to her best interests and premature to rule out the treatments set out in Part 2 of the updated treatment plan, numbers (2) to (6). ... Mr McKendrick submits that it would not be in HB's best interests that the potentially last moments of her life were lived with her undergoing the violent and invasive procedures necessary in providing CPR, that it would be a traumatic scene for her children to witness in her final moments. I entirely accept those submissions and the force in them, but key to the decision must be the wishes and feelings of HB and it is plain that administering CPR in the event of a further collapse and giving her, albeit a very, very small chance of life, is what she would wish. In my judgment, at the moment, it remains in her best interests for that treatment to be provided to her. I entirely accept that there will undoubtedly come a time when such treatments would no longer be in her best interests but I am entirely satisfied that that stage has not been reached yet." 2019‑02‑12 09:31:12 2018 cases, Cases, Judgment available on Bailii, Medical treatment cases

* Australian case on capacity and ECT PBU v Mental Health Tribunal (2018) VSC 564Headnotes from judgment: (1) "ADMINISTRATIVE LAW – appeal – decisions of Victorian Civil and Administrative Tribunal (‘VCAT’) that two persons with mental illness be compulsorily subjected to electroconvulsive treatment (‘ECT’) – determination that they lacked the capacity to give informed consent to or refuse treatment – whether VCAT properly interpreted and applied requirement that person be able to ‘use or weigh’ information relevant to decision – further requirement that there be no less restrictive way for the person to be treated – whether this requirement only met where treatment immediately needed to prevent serious deterioration in person’s health or serious self-harm or harm to another – ‘capacity to give informed consent’ – Mental Health Act 2014 (Vic) ss 68, 69, 70, 72, 93 and 96." (2) "HUMAN RIGHTS – two persons having mental disability found by VCAT to lack capacity to give informed consent to or refuse ECT – whether incompatible with human rights to self-determination, to be free of non-consensual medical treatment and to personal inviolability – assessing capacity compatibly with those rights and the right to health – applicable principles – dignity of risk – Charter of Human Rights and Responsibilities Act 2006 (Vic) ss 8(3), 10(c), 13(a), International Covenant on Economic, Social and Cultural Rights art 12(1), Convention on the Rights of Persons with Disabilities arts 12(4), 24." 2019‑02‑04 14:50:50 2018 cases, Cases, Judgment available on MHLO, Judgment missing from Bailii, Medical treatment cases

* Tracheostomy tube, escalation, morphine Leeds Teaching Hospitals NHS Trust v JF [2018] EWCOP 32"... N suffered a cardiac arrest in the taxi as she was arriving at Leeds General Infirmary and as a result for some 20 minutes or so ceased breathing and suffered a severe hypoxic injury. In consequence she has suffered a very significant and severe brain injury. The position now and since then has remained that she is essentially unconscious. ... The issues before me have been threefold. First, whether or not the tracheostomy tube should be removed. ... The second issue has rather retreated in significance. I have to consider whether or not N should receive an escalation of invasive care or treatment, in particular vasoactive drugs, renal replacement therapy, ventilation treatment that requires central venous action or CPR. ... That brings me on to morphine, and that is a difficult issue." 2018‑11‑12 21:50:46 2018 cases, 39 Essex Chambers summary, Cases, Judgment available on Bailii, Medical treatment cases

* Novel treatment University College London Hospitals v KG [2018] EWCOP 29"In this case the University College London Hospitals NHS Foundation Trust seeks the court's authority to administer a treatment known as PRN100 to a patient KG. KG is represented by the Official Solicitor. KG, the Official Solicitor on his behalf, his family and the Trust all ask for the court's approval. The matter is before the court because PRN100 has never been tested on or administered to any person anywhere. It is thus a completely novel treatment." 2018‑10‑31 22:26:36 2018 cases, 39 Essex Chambers summary, Cases, Judgment available on Bailii, Medical treatment cases

* Sperm Y v A Healthcare NHS Trust [2018] EWCOP 18"This application was made by Y on 12 July 2018 when I was sitting as the emergency applications judge. It required urgent determination by reason of the critical medical condition of Z, Y's husband. Y sought the following relief: (a) A declaration that, notwithstanding her husband's incapacity and his inability to consent, it was lawful and in his best interests for his sperm to be retrieved and stored prior to his death; (b) An order pursuant to section 16 of the Mental Capacity Act 2005 directing that a suitable person should sign the relevant consent form for the storage of Z's sperm on her husband's behalf." 2018‑08‑18 08:47:12 2018 cases, Cases, Judgment available on Bailii, Medical treatment cases

* Court order not always necessary for withdrawal of CANH NHS Trust v Y [2018] UKSC 46"The question that arises in this appeal is whether a court order must always be obtained before clinically assisted nutrition and hydration, which is keeping alive a person with a prolonged disorder of consciousness, can be withdrawn, or whether, in some circumstances, this can occur without court involvement. ... In conclusion, having looked at the issue in its wider context as well as from a narrower legal perspective, I do not consider that it has been established that the common law or the ECHR, in combination or separately, give rise to the mandatory requirement, for which the Official Solicitor contends, to involve the court to decide upon the best interests of every patient with a prolonged disorder of consciousness before CANH can be withdrawn. If the provisions of the MCA 2005 are followed and the relevant guidance observed, and if there is agreement upon what is in the best interests of the patient, the patient may be treated in accordance with that agreement without application to the court. I would therefore dismiss the appeal. In so doing, however, I would emphasise that, although application to court is not necessary in every case, there will undoubtedly be cases in which an application will be required (or desirable) because of the particular circumstances that appertain, and there should be no reticence about involving the court in such cases." 2018‑07‑31 21:46:38

* Withdrawal of CANH NHS Windsor, Ascot and Maidenhead CCG v SP (Withdrawal of CANH) [2018] EWCOP 11"Windsor, Ascot and Maidenhead CCG have applied to the court for a personal welfare order in respect of SP. The order sought is for a Declaration and Order that it is not in SP's best interests for Clinically Assisted Nutrition and Hydration (CANH) to be continued. In tandem with the withdrawal of CANH palliative care will be provided. The consequence is an expectation that SP will die within 7-14 days. ... In early 2015 she was diagnosed as being in a continuing vegetative state and in April 2015 as being in a permanent vegetative state (PVS). She has been in receipt of CANH since October 2014." 2018‑04‑20 19:54:41 2018 cases, Cases, Judgment available on Bailii, Medical treatment cases

* Medical treatment, costs, anonymity Re SW [2017] EWCOP 7(1) "[A]s matters stand, the transplant being proposed cannot proceed, whatever the court may say or do. As it has been presented to the court, this scarcely coherent application is totally without merit, it is misconceived and it is vexatious. It would be contrary to every principle of how litigation ought to be conducted in the Court of Protection, and every principle of proper case management, to allow this hopelessly defective application to proceed on the forlorn assumption that the son could somehow get his tackle in order and present a revised application which could somehow avoid the fate of its predecessor." (2) "As against the son, the claim for costs could not, in my judgment, be clearer. Given everything I have said, this is the plainest possible case for departing from the ordinary rule, set out in rule 157 of the Court of Protection Rules 2007, and applying the principles set out in rule 159. ... [B]oth Dr Waghorn and Dr Jooste, in my judgment, are persons against whom a costs order can be made even though are not, formally, parties to the litigation – and, if that is so, then for the same reasons as in relation to the son, it is, in my judgment, fair and just to order them to pay the costs." (3) "There is no reason why either SW or SAN should be named, and, indeed, every reason why they should not. Nor, in all the circumstances, is there any reason why the son should be named. Dr Waghorn and Dr Jooste, however, stand in a very different position. There is a very strong public interest in exposing the antics which these two struck-off doctors have got up to, not least so that others may be protected from their behaviour." 2018‑03‑28 22:40:05 2017 cases, Anonymisation cases, COP costs cases, Cases, Judgment available on Bailii, Medical treatment cases, Reporting restriction order cases

* Treatment on basis of active deception Re AB [2016] EWCOP 66"I am asked to, and I do approve, a treatment regime for AB, which involves the administration of medication to her on a basis of deception. Not merely passive deception, which, to use a legal phrase might be characterised as suppressio veri, but active deception, which lawyers might describe as suggestio falsi. It is debateable whether there is in fact much moral difference between the two types of deception, but what is being proposed here is a treatment regime, an administration of medication, on the basis of active deception of AB. I only have to state this for the unusual nature of the case to be revealed, but the circumstances in which these facts arise demonstrate that such a course is manifestly required in the best interests of AB, notwithstanding that her personal wishes and feelings would be entirely contrary to the course that is going to ensue. AB is infected with HIV. ... The order will provide, however, that if the truth emerges to AB and she moves to a position of active resistance then the matter will have to be reviewed, and the Court will have to consider, in that situation, whether to move to forced administration of these drugs, which would be a very difficult decision to make, because it would not be a one-off administration of treatment, but would be a quotidian administration of treatment, which is a very different state of affairs to that which is normally encountered in this Court." 2018‑03‑28 09:45:15 Cases

* Nerve agent poisoning SSHD v Skripal [2018] EWCOP 6"On 4 March 2018 Sergei Skripal and Yulia Skripal were admitted to hospital in Salisbury. Tests carried out by Defence Science and Technology Laboratory at Porton Down concluded that they had been exposed to a nerve agent. Both Mr and Ms Skripal remain in hospital under heavy sedation. The precise effect of their exposure on their long term health remains unclear albeit medical tests indicate that their mental capacity might be compromised to an unknown and so far unascertained degree. The fact of their exposure to a nerve agent has already had significant consequences on the wider domestic and international stage which I need not go into for the purposes of this judgment. However central to the application before me is the fact that on 14 and 16 March 2018 the UK government issued a formal invitation to the Director-General of the Organisation for the Prohibition of Chemical Weapons (OPCW) to send a team of experts to the United Kingdom 'to assist in the technical evaluation of unscheduled chemicals in accordance with Article VIII 38(e).' This in effect is to independently verify the analysis carried out by Porton Down. In order to conduct their enquiries the OPCW wish to: (i) Collect fresh blood samples from Mr and Ms Skripal to (a) undertake their own analysis in relation to evidence of nerve agents, (b) conduct DNA analysis to confirm the samples originally tested by Porton Down are from Mr and Ms Skripal; (ii) Analyse the medical records of Mr and Ms Skripal setting out their treatment since 4 March 2018; (iii) Re-test the samples already analysed by Porton Down. Because Mr Skripal and Ms Skripal are unconscious and neither are in a position to consent to the taking of further blood samples for these purposes or to the disclosure of their medical records Salisbury NHS Foundation Trust have quite properly confirmed to the UK Government that a court order would be required to authorise (a) and (b) above." 2018‑03‑28 09:35:57 2018 cases, Cases, Judgment available on Bailii, Medical treatment cases

* Withdrawal of CANH M v A Hospital [2017] EWCOP 19"This judgment is given: (a) To explain why CANH was withdrawn from M, a person in a minimally conscious state (MCS). (b) In response to the request of the parties for clarification of whether legal proceedings were necessary or not when there was agreement between M's family and her clinicians that CANH was no longer in her best interests. (c) To explain why the court appointed M's mother, Mrs B, as her litigation friend, rather than the Official Solicitor. The short answer to these questions is that: (a) CANH was withdrawn because it was not in M's best interests for it to be continued. The evidence showed that it had not been beneficial for the previous year. (b) In my view, it was not necessary as a matter of law for this case to have been brought to court, but given the terms of Practice Direction 9E and the state of the affairs before the very recent decision of the Court of Appeal on 31 July in the case of Briggs [2017] EWCA Civ 1169B, it is understandable that the application was made. (c) Mrs B was appointed as litigation friend because she was a proper person to act in that role: the fact that she supported the withdrawal of her daughter's treatment did not show that she had an adverse interest to her." 2018‑02‑16 23:28:05 2017 cases, Cases, ICLR summary, Judgment available on Bailii, Medical treatment cases

* Withdrawal of CANH NHS Trust v Y [2017] EWHC 2866 (QB)"This is a claim for a declaration under CPR Part 8 that it is not mandatory to bring before the Court the withdrawal of Clinically Assisted Nutrition and Hydration ("CANH") from a patient who has a prolonged disorder of consciousness in circumstances where the clinical team and the patient's family are agreed that it is not in the patient's best interests that he continues to receive that treatment, and that no civil or criminal liability will result if CANH is withdrawn." 2017‑11‑26 01:18:30 2017 cases, Cases, ICLR summary, Judgment available on Bailii, Medical treatment cases

* Minimally conscious state Abertawe Bro Morgannwg University LHB v RY [2016] EWCOP 57"On 12th October this year the applicant Health Board applied to this court for declarations both as to 'capacity' and 'best interests' under the Mental Capacity Act 2005, concerning RY, to permit withdrawal of ventilation, withholding of life-sustaining treatment, and provision of palliative care only. RY's daughter has from the beginning asserted that, when ventilation is removed, life-sustaining treatment should be provided. I am asked to approve an order filed with the consent of all the parties which provides for some life-sustaining treatment, but not CPR or further intensive care. ... However, there have been a number of recent videos taken of RY ... which have led [Dr Badwan] to conclude that RY is not in a vegetative state, but is in a minimally conscious state with some signs of being in upper minimally conscious state. ... This morning the very experienced advocates in this case presented a plan, by agreement, in which it was proposed that RY underwent a tracheostomy under general anaesthetic and, transferred to a suitable unit for further treatment and/or assessment. ... As a Judge sitting in the Court of Protection, I have experience of litigants seeking very extensive assessments and re-assessments, in a way that occurred in the Family Division in Children Act 1989 proceedings, most particularly in public law care proceedings. The reasons for both strike me as similar, namely that the decisions the Court is asked to make are of such great importance and carry such profound consequences that there is, I think, a forensic instinct to leave no stone unturned. I am bound to say however, that I sometimes feel that I am being asked to authorise a petrological survey on the upturned stone. Just as the Family Justice reforms have re-emphasised the real dangers to vulnerable children caused by avoidable delay, so to, it seems to me, practitioners in this field must recognise that delay which is not, on a true analysis, either constructive or purposeful is almost certainly damaging and thus inimical to P's welfare. Though avoidance of delay is not a statutory imperative in the Mental Capacity Act 2005 the principle is now so deeply embedded in the law of England and Wales and across every jurisdiction of law that it should be read into Court of Protection proceedings as a facet of Article 6 and 8 ECHR. It requires to be restated that the Court of Protection Rules provide for the Court to restrict expert evidence and assessment, application must be made by completing form COP9. ... Given the scale of the hypoxic damage, the preponderant evidence suggests that any significant improvement may be rather a forlorn hope. I think RY's family should be under no delusion as to the prospects. That 'flicker of hope', says the Official Solicitor, is one that should be pursued on RY's behalf. Ultimately, I have acceded to that submission but I do so on a very particular basis and that is that the assessment process, which has been outlined in framework this afternoon, is carefully monitored..." 2016‑12‑18 21:20:13

Re W (Medical Treatment: Anorexia) [2016] EWCOP 13, [2016] MHLO 35 — "In this case, Miss W, a young woman aged 28, has suffered from a severe and enduring eating disorder for 20 years, with physical, social and psychological consequences of the kind described above. In this judgment I will call her W. Since the age of 11, she has had six admissions for inpatient treatment, spread between five units around the country and amounting to about 10 years in total. Her current admission has lasted for 2½ years and yet, despite the most intensive support, she is barely eating and is losing weight at the rate of 500 g – 1 kg per week. She now weighs less than 30 kg and her BMI is 12.6. If she continues to lose weight at this rate, she will die. ... The outcome is that, accepting the unanimous professional view, I approve the plan of the Health Board. This is that W should now be discharged into the community with a closely thought-out package of support for her and her family. Given W's fragile condition, it is a plan that has only been arrived at after the most anxious consideration by her care team. It will at first seem counterintuitive that someone so ill should be discharged from hospital. The conventional assumption is that hospital treatment is likely to bring benefits, but the evidence has persuaded me that in this case that is not so. The outcome is to some extent in accordance with W's wishes, which I will describe below." 2016‑09‑25 20:53:00 2016 cases, Judgment available on Bailii, Medical treatment cases, No summary, Transcript

Re CS (Termination of Pregnancy) [2016] EWCOP 10, [2016] MHLO 34 — "This is an application by a Hospital Trust for orders in respect of a young woman, who I will refer to as CS, who is said to lack capacity and in respect of whom the Trust seeks an order that it would be in her best interests to undergo surgery terminating her current pregnancy. This hearing is being conducted in the Court of Protection in open court in accordance with the Rules but subject to a reporting restriction order which I made earlier this afternoon." 2016‑08‑31 21:30:24 2016 cases, Judgment available on Bailii, Medical treatment cases, No summary, Transcript

The NHS Acute Trust v C [2016] EWCOP 17, [2016] MHLO 32 — "The applicant Trusts provide obstetric and psychiatric care and services to the respondent, C. They have made applications for an order (i) in the Court of Protection to permit the applicants to undertake various steps and measures in respect of C's forthcoming labour; and (ii) a reporting restrictions order." 2016‑08‑31 20:59:57 2016 cases, Judgment available on Bailii, Medical treatment cases, No summary, Transcript

* Death Re A (A Child) [2016] EWCA Civ 759"This is an appeal against the making of a declaration by Mrs Justice Parker on 20 June 2016 whereby she declared that: 'It is lawful and in A's best interest to remove his respiratory support by extubating him and, if he becomes unstable, not to reintroduce his respiratory support again but instead generally to furnish such treatment by way of pain relief or sedation and nursing as may be appropriate to ensure that A suffers the least distress and pain at the time and in the manner of his dying.'" 2016‑07‑13 22:02:15

* Death A Local Health Board v Y (A Child) [2016] EWHC 206 (Fam)"In all the circumstances, therefore, I conclude that the course proposed by the clinicians is in Y's best interests. In accordance with the parties' ultimate agreement, I therefore conclude that (1) It is lawful and will be in Y's best interests for him to be extubated at the point where the clinicians, following discussion with Y's family, consider that his condition is optimal for extubation, and that "optimal" for these purposes is likely to mean when (a) he remains on minimal ventilation: (b) he has a body temperature of less than 37.5 and (c) that he has not required CPR for the previous 12 hours; (2) Upon extubation, it is lawful and in his best interests not to re-intubate him if he is unable to support his own respiration. (3) Upon extubation, it is lawful and in his best interests not to receive CPR (save for stimulation, which may be provided) or ventilation or inotropes." 2016‑02‑17 22:02:45

M v Mrs N [2015] EWCOP 76, [2015] MHLO 102It was in the best interests of N, who was in a minimally-conscious state, not to continue to receive clinically assisted nutrition and hydration. The judge concluded that: "Ultimately, I have concluded that her wishes, so thoughtfully presented by her family, coupled with the intrusive nature of the treatment and its minimal potential to achieve any medical objective, rebut any presumption of continuing to promote life. Quite simply, I have come to the conclusion that it would be disrespectful to Mrs. N to preserve her further in a manner I think she would regard as grotesque." 2015‑11‑23 21:41:29 2015 cases, Brief summary, Judgment available on Bailii, Medical treatment cases, Transcript

* Amputation - religious beliefs Wye Valley NHS Trust v B [2015] EWCOP 60"The issue in this case is whether it is lawful for the doctors treating Mr B, a 73-year-old gentleman with a severely infected leg, to amputate his foot against his wishes in order to save his life. Without the operation, the inevitable outcome is that he will shortly die, quite possibly within a few days. If he has the operation, he may live for a few years. Mr B also has a long-standing mental illness that deprives him of the capacity to make the decision for himself. The operation can therefore only be lawfully performed if it is in his best interests. ... Having considered all of the evidence and the parties' submissions, I have reached the clear conclusion that an enforced amputation would not be in Mr B's best interests. Mr B has had a hard life. Through no fault of his own, he has suffered in his mental health for half a century. He is a sociable man who has experienced repeated losses so that he has become isolated. He has no next of kin. No one has ever visited him in hospital and no one ever will. Yet he is a proud man who sees no reason to prefer the views of others to his own. His religious beliefs are deeply meaningful to him and do not deserve to be described as delusions: they are his faith and they are an intrinsic part of who he is. I would not define Mr B by reference to his mental illness or his religious beliefs. Rather, his core quality is his "fierce independence", and it is this that is now, as he sees it, under attack." 2015‑09‑30 20:48:32 2015 cases, Cases, Judgment available on Bailii, Medical treatment cases

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