Mostyn J’s judgment in a novel case concerning withdrawal of life sustaining treatment in the Court of Protection’s first ever Skype trial

In a trial lasting three days, conducted entirely remotely through the medium of Skype, no one could fail to be moved when watching a video clip of a man in his seventies, known as “AF” in these proceedings, moving his hand rhythmically, marking the beat to the tune of Irish Eyes. What made this so poignant was that AF had suffered a catastrophic stroke in May 2016 which rendered him severely disabled and incapacitous, but still sentient and, as the Judge observed, AF was plainly enraptured listening to the musician playing before him.   

This very sad case found its way into a newly-styled virtual courtroom the day after Boris Johnson urged the nation to avoid non-essential contact in the midst of the Covid-19 pandemic. Thus began the first ever remote trial on the most sensitive of issues – should AF continue to receive life-sustaining nutrition and hydration via a percutaneous gastrostomy (“PEG”) or should it be withdrawn, a decision which would almost certainly lead to his death.

Private Client analysis: The judgment considers the correct legal framework to apply where a person before the Court of Protection has capacity to make decisions regarding their medical treatment but could lose that capacity under certain circumstances. Rhys Hadden examines the case.

An NHS Foundation Trust and another v R [2020] EWCOP 4, [2020] All ER (D) 07 (Feb)

What are the practical implications of this case?

The judgment deals with a number of different issues in relation to serious medical treatment cases, particularly in cases involving obstetric care and Caesarean sections.

The central focus of the decision is concerned with identifying the correct legal framework to be applied where the Court of Protection is confronted with the position that the person before it currently has capacity to make the relevant decision(s) but there is clear evidence that under some circumstances they may not do.

The courts in the time of coronavirus: a personal perspective on the first remote hearing during the crisis

Mostyn J hears trial concerning withdrawal of life sustaining treatment with five parties and at least 20 participants over Skype for Business  (REVISED POST)*

In December 2019, Keehan J presided over a directions hearing in a serious medical treatment application brought by a CCG.  A dispute had arisen as to whether or not it was in the best interests of A, a man in his 70s who suffered a stroke in 2016, to continue to receive clinically assisted nutrition and hydration (CANH).  A’s daughter believes CANH should be removed; his GP thinks it should stay in place. A is not in a prolonged disorder of consciousness: despite significant impairment, he communicates with those caring for him in gestures and occasional words, and enjoys seeing animals and children, and hearing poetry.

In itself, this would be an unusually difficult and sensitive case for the Court of Protection, and Keehan J listed it for four days, including a day of judicial reading time.  As preparation progressed, it became clear that it was going to be a tight timetable. Between them, the five parties (CCG, A, represented by the Official Solicitor, A’s daughter, A’s GP, and the local authority) were calling eleven witnesses to give oral evidence, including three independent expert consultants; all five parties would be making closing submissions; and the evidence available to the court ran to well over 4000 pages.  What makes this case even more unusual is that the judge listed it to start on Tuesday 17 March 2020, less than 24 hours after the nation was directed to avoid all non-essential contact to stem the rising tide of Covid19.

At 6.50 am on 10 February 2020 Matt Hancock signed off the Health Protection (Coronavirus) Regulations 2020, SI 2020/129. The press reported that the urgent need for the regulations was that some people subject to quarantine by agreement had said they could see little point in the process and intended to leave. I suggested when I last wrote about quarantine that the lack of an enforcement power made contractual agreement a shaky basis for detaining hundreds of people for 14 days.

The Secretary of State has now put in place a raft of coercive powers, including a power to hold people in isolation and for a constable to take someone back to isolation – using reasonable force – and to enter premises to enforce the regulations.  This note summarises those powers.

The new regulations create additional powers to control people who may have coronavirus where the Secretary of State declares that the transmission of coronavirus is a “serious and imminent threat to public health” by way of a notice on the gov.uk website – gone are the old days of publishing notices in the Official Gazette.  At the same time as making the regulations the Secretary of State declared that such a threat existed, and that, for the purposes of exercising these powers, Wuhan and Hubei province were “infected areas” and that Arowe Park and Kents Hill Park hospitals were “isolation facilities”.

A note on the law and practice of quarantine – of individuals, of groups and of places, of the unwell and of the healthy.

  1. Kaci Hickox is a Johns Hopkins’ qualified nurse who worked as a team leader in an Ebola treatment unit in Sierra Leone in September 2014. When she arrived at Newark Liberty International Airport on 22 October 2014 she was taken into custody for 80 hours.  On the same day the governor of New Jersey had signed an executive order providing that travellers arriving at New Jersey who were asymptomatic but at high risk of exposure to Ebola could, if out of state residents, be transferred to a “temporary housing arrangement”.  In response to her detention Ms Hickox brought a claim against the state of New Jersey, including for violation of her right to be free from deprivation of liberty, denial of due process and false imprisonment.
  1. Time Magazine gave “Ebola fighters” their Person of the Year award in 2014, the article noting of Ms Hickox’s quarantine: “The problem with irrational responses is that they can cloud the need for rational ones”.
  1. In July 2017 Ms Hickox entered into a settlement agreement with the state of New Jersey. The parties agreed to a new Addendum to the “New Jersey Mandatory Quarantine and Screening Protocols” for Ebola Virus disease.  The state agreed only to use quarantine “insofar as a medically and epidemiologically necessary” and only after less restrictive measures had been “explicitly explored”.  An order providing for quarantine would have to give a start date and an end date and state the legal authority and medical basis on which it was issued.  It would need to explain why less restrictive options had been rejected and confirm the right of the person in quarantine to a lawyer and to challenge the order[1].

Judges in the Family Division and the Court of Protection are regularly asked to perform the unenviable task of balancing the pros and cons of continuing life-sustaining treatment. The Judge’s decision determines whether the person at the heart of those proceedings should live or die. As the Supreme Court confirmed in a number of appeals including those launched on behalf of both Charlie Gard and Alfie Evans, the Judge must apply the best interests tests in serious medical treatment cases. Thus, although the individual facts will frequently place a great burden on the Court, the legal test at least, is clear.  

In Manchester University NHSFT v Midrar Namiq (a minor) and others, [2020] EWHC 6 (Fam) Lieven J was asked to consider a different, but equally momentous issue – whether the child was in fact already dead.

The Trust argued that the Court’s function was to assess whether the relevant testing had established “on the balance of probabilities” that the child was brain stem dead. In contrast, the family’s representatives argued that the Court’s role was to apply the best interests test to the question of whether the intensive care support that was still keeping oxygenated blood circulating the body should be removed.