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.

The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust and Dorset Healthcare University NHS Foundation Trust and SE (by her litigation friend, the Official Solicitor) [2018] EWCOP 45

When incapable patients require life saving surgery against their wishes, judges of the Court of Protection are readily available to provide best interests declarations at short notice. However, making such life and death decisions under pressure will never be the preferable approach. As this recent case shows, the court will look disapprovingly on NHS Trusts who leave such applications to the very last minute. All NHS Trusts should ensure their staff understand the correct procedural routes to approach the court and that these are used before a difficult case has become an emergency.

Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust v TG and another [2019] EWCOP 21

What are the practical implications of this case?

‘The Lord giveth, and the Lord taketh away’ (Job 1:21). If this phrase reflects the patient’s (P) views on life, the Court of Protection will need to take it into consideration, as should the treating hospital prior to bringing an application for withdrawal of life-sustaining treatment. In this case, the Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust (the Trust) sought to withdraw endo-tracheal intubation, but the same principles would apply to withdrawal of clinically-assisted nutrition and hydration (CANH).

The recent case of Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust v TG and another confirms that the focus of any decision to withdraw CANH must remain firmly on the individual at the heart of the case, and on their wishes, views and beliefs.

The issue in this case was whether continuation of intubation was in the best interests of P. Withdrawal of treatment would certainly lead to P’s death. The Trust argued that given the medical evidence, there was no benefit in continuing treatment except that P would remain alive.

On 16 July 2019, Mr Justice Hayden, the Vice President of the Court of Protection, handed down his judgment in the case of LB Tower Hamlets v NB & AU [2019] EWCOP 27 which considered the test for capacity to consent to sexual relations.

Why is this judgment significant?

The case considered whether ‘the test’ could and should be nuanced to take account of the particular circumstances of P as opposed to simply being issue or act specific. Such an approach could be viewed as a development from previous authorities; including the recent Court of Appeal decision of B v A Local Authority [2019] EWCA Civ 913.

The very clear message from this judgment is that it is essential to consider capacity to consent to sexual relations (and indeed when assessing P’s capacity to make decisions in all areas of life) based on the full facts of P’s situation, and with an awareness that a conclusion that P lacks capacity will be an interference with their rights.

The court did not make any conclusions as to whether NB had, or lacked capacity to consent to sexual relations, and it may be that a final judgment will be handed down in due course if the Local Authority undertake a reassessment of NB’s capacity in the light of the judgment.

Williams J approves plan for covert sedation and C-section of incapacitous 25 year old

The best laid plans …

In NHS Trust v JP [2019] EWCOP 23[1], in a decision which emphasises the importance of an overall evaluation of best interests rather than placing undue focus on any one of several important factors, Williams J made declarations that a pregnant woman with a learning disability lacked capacity to make decisions about her obstetric care and the delivery of her baby and that, notwithstanding her wish to have a natural delivery, it was in her best interests to undergo a caesarean section, with restraint and covertly administered sedation if required, because of her perceived inability to cope with a natural delivery.

In the event, JP went into labour spontaneously the day after the hearing, and delivered a healthy baby naturally at the hospital, with no restraint or sedation being required. The fact that JP confounded the expectations of the clinicians, the lawyers and the court does not, of course, mean either that the application was ill-founded or that the court’s decision was wrong, but as the judge commented in a postscript to his judgment: “The capacity for individuals to confound judges’ assessments is a reminder (to me at least) of the gap between probabilities and actuality.”