Barnsley Hospital NHS Foundation Trust  -v-  MSP [2020] EWCOP 26    Judgment 3 June 2020  here

Whatever the media headlines, this is not a case about choosing to die, it is about an adult’s capacity to shape and control the end of his life. This is an important facet of personal autonomy which requires to be guarded every bit as jealously for the incapacitous as for the capacitous[47].

In a thoughtful and sensitive judgment, the Vice President of the Court of Protection has emphasised again how the principle of sanctity of life may give way to the right of self-determination; and how P’s best interests may be best served by giving effect to what the patient would choose for themselves were they able to do so, even if that choice means death.

The issue

MSP, a man in his thirties, was heavily sedated in ICU following abdominal surgery to insert a stoma.  He was ventilated and receiving total parenteral nutrition.[1]  MSP had experienced serious gastrointestinal problems for a decade and had written an “Advanced Directive” spelling out the terms on which he did – and did not – wish for medical treatment to prolong his life.  With the need for a stoma now permanent, and the prospect of an equally permanent need for artificial nutrition and hydration, the question for the court was whether it was in MSP’s best interests to continue to receive such treatment.

Testamentary capacity and Lord Templeman’s will

Introduction

On 19 March 2020, Mr Justice Fancourt handed down judgment in the matter of Re Baron Templeman of White Lackington (Deceased)[2020] EWHC 632 (Ch). The case concerned the validity of the last will of Lord Templeman, who sat in the House of Lords from 1982 to 1994. No post about Lord Templeman would be complete without reference to his forthright and uncompromising manner. One of the many accounts of his dealings with Counsel included a case where he had been characteristically robust with Leading Counsel. Having concluded with the Leader he asked whether Junior Counsel wished to make any submissions. ‘Not without a helmet my Lord’ came the reply.

Lord Templeman died in 2014 and the sole issue in the case was whether he had testamentary capacity when he executed his last will in 2008, 6 years before. The 2008 will was neither witnessed nor approved by a medical practitioner.

The claimants (the stepdaughters of Lord Templeman’s late wife) sought to propound the 2008 will, whereas the first and second defendants (the younger son and daughter-in-law of Lord Templeman) contended that it was invalid.

The ‘golden rule’ places a requirement on a solicitor or will writer to assess whether the testator has testamentary capacity, and if necessary, to obtain medical evidence to support this. Incredibly (and in an ironic twist), the development of the golden rule was advanced by Lord Templeman himself in Kenward v Adams ChD 29 November 1975, and Re Simpson [1977] 121 SJ 224 where he determined that ‘… the making of a will by an aged or seriously ill testator ought to be witnessed or approved by a medical practitioner who has satisfied himself of the capacity and understanding of the testator, and records and preserves his examination or findings’.

As stated by Mr Justice Fancourt at [116] it is ‘commonplace that people who are able dispassionately to give good advice to others do not always follow such advice themselves, or believe themselves to be in need of it’.

 This blog is written towards the beginning of the Covid-19 lockdown. We are not yet three weeks in, and do not know what the future holds.  This post has already been updated once since publication and in the fast paced news of coronavirus, more updates will come.  This post therefore may not be an exhaustive analysis, but we will revisit the subject as and when developments require.  We would also welcome any relevant new information on the topic, especially from those at the front line: please send to This email address is being protected from spambots. You need JavaScript enabled to view it..

 The Government is clear that there is not, and is unlikely to be, a situation where there are more patients nationally requiring ventilation than there are ventilators.  If achieved, avoidance of the situation faced by doctors in Italy and Spain will come about by a combination of increased supply of ventilators, moving patients and ventilators around to match supply to demand, and the application of tough triage criteria, so that access to ventilation is limited to those likely to make a recovery.

But avoidance cannot be guaranteed. Local surges in demand will occur, and may lead to temporary shortages.  The risk of demand exceeding supply exists.  News reports in The Guardian and Daily Mail suggest that this has already happened in some hospitals.

Were that risk to eventuate, the withdrawal issue would arise:

Can a ventilator ever lawfully be removed from a ventilated patient who may be deriving benefit from it, for the purpose of providing that ventilator to different patient?

If it can, how should withdrawal and reallocation decisions be made?

In our view, these questions should be asked and answered now, before the risk eventuates, and in the profoundest hope that it never does.

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.