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Best interests and serious medical treatment where the person lacking capacity has delusional beliefs

8 September 2017, by Bethan Harris

CapacityCourt of Protection

Bethan Harris

NHS Foundation Trust v QZ (by her litigation friend, the Official Solicitor) [2017] EWCOP 11, 6 June 2017, Hayden J

The Trust sought an order to permit investigative procedures under general anaesthetic to detect the cause of QZ’s postmenopausal bleeding and if a cancer was found, urgent keyhole surgery.

QZ was in her sixties and had a diagnosis of treatment resistant paranoid schizophrenia.

She lacked capacity to make decisions about her medical treatment.  She would not agree to investigation or surgery. The risk of cancer being present was 30 – 50 %. The care plan would involve a degree of force. QZ had long-standing delusional beliefs that she was being poisoned by her carers or doctors and was at risk of being raped by them. Thus the contemplated interventions collided directly with her delusional belief structure. Her relationships with care staff would deteriorate rapidly if she perceived a breach of trust, leading to deterioration in her mental state. The doctors agreed that significant mental health deterioration was inevitable if she underwent the procedures, but her treating psychiatrist considered that she had capacity to regain trust.

The court referred in particular of Aintree University Hospital NHS Foundation Trust v James and others [2013] UKSC and Wye Valley v B [2015] EWCOP 60. In argument it was suggested QZ’s case was analogous to Wye Valley Trust v B.  In that case Peter Jackson J rejected a submission that wishes and feelings when they are “intimately connected with the causes of lack of capacity” would attract very little weight.

Hayden J held that, whilst delusional beliefs should never be discounted merely because they are irrational, the weight they are to be afforded will fall to be considered in the context of the evidence a as a whole. The circumstances of QZ’s life were very different to that of B. Her ability to forge bonds of trust in the future was just as much a part of who she was as her paranoid and delusional beliefs. There was a real prospect that she may recover a life with happiness and dignity. Permitting the treatment here was, to adopt Peter Jackson J’s careful terminology, not fighting QZ but fighting on her behalf. The treatment would be authorised.

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