On Wednesday 26th May, Sir Nicholas Walls sitting in the Court of Protection took the decision to declare that an NHS Foundation Trust should be allowed to sedate one of its patients, a 55 year old woman with significant learning difficulties, in order that she should undergo surgery that may, potentially, save her life.

The woman, identified in the judgment as PS, to preserve her anonymity, was recognised as having a “a significant impairment to her intellectual functioning as a consequence of her learning disability.” PS therefore lacks capacity under the Mental Capacity Act 2005. PS has cancer of the uterus, which has spread to her cervix. Without surgical intervention the cancer would be sure to spread elsewhere in her body and would eventually, inevitably kill her. The potentially life-saving surgery involves a hysterectomy an another procedure which would remove PS''''s fallopian tubes and her ovaries. PS had consented to undergo the operation but later failed to turn up for treatment and on occasions refused treatment, presumably withdrawing her consent. It was submitted that her reluctance received treatment was due to a fear of hospitals and injections. This fear has made it impossible for the Trust to ascertain the actual extent of the cancer, as PS cannot undergo what would usually be a routine MRI scan. The scan in simply not a viable option because it requires the patient to keep still and lie in a confined space for a prolonged period, something which PS would find excruciating due to her fear of treatment and claustrophobia, with which she also suffers. As a result of her repeated refusals to undergo surgery, the team of medical professionals treating have come to decision that “special arrangements” need to be put in place to ensure that PS undergoes treatment and remains in hospital to recover afterwards. It was the procedure which formed the basis of its application to the court. Various medical experts employed by the Trust gave evidence explaining that a procedure would be put in place whereby a consultant anaesthetist would accompany an ambulance to PS''''''''''''''''''''''''''''''''s home. Under this procedure, if she were to refuse the operation once again the ambulance staff may sedate her by offering her a sedative contained in a drink described as being similar to Ribena. It was submitted on behalf of the trust that a “worst case scenario” may arise whereby PS would need to be injected with a “safe” sedative such as Ketamine. Reasonable force, it was added, may be necessary in order to administer this drug should all other methods of persuasion (and presumably deception) fail. The Trust conceded that the use of such a sedative may give rise to side-effects such a breathing difficulties, which is why it would be necessary to have such a high-ranking anaesthetist present. The Trust further submitted that it would be necessary to detain PS in hospital after her operation. Whilst detained, she would need to be given fluids intravenously by way of a tube. If this measure were taken it would be necessary to bandage this tube in such a way as to make it impossible for her to pull it out of her arm. PS would also remain under sedation in the form of analgesic medication due to the likelihood of her attempting to escape from the care of the Trust. It was also submitted that it may be necessary to use reasonable force to return her to her bed in the event this did happen. It was submitted by a member a nursing staff who had worked closely with PS that there had been many attempts to persuade her have the operation and that she would continue to make “every effort” to avoid the use sedative however the nurse went onto to say that ultimately it would be likely to be necessary because of PS''''s proven reluctance and fear of treatment. In his judgment Sir Walls made it clear that he believed this decision was the obvious conclusion that should be drawn ,stating that it was in PS''''s “best interests” to have the operation and that she should be sedated and detained in hospital to facilitate her recovery if these steps proved to be necessary. Sir Walls also commented on the way in which the Trust had so far dealt with this case saying that he was: “Impressed with care and thought which have gone into ensuring that PS receives treatment which she plainly needs and which it is plainly into her interests to have” This case has unsurprisingly been received with mixed opinions from mental health and disability organisations. It was reported by Mencap that its own head of campaigns and policy, David Congdon, had praised the judgment and commended the healthcare professionals involved with the case. He stated: "We believe that people with a learning disability have the same right to treatment or to refuse treatment as anyone else. However, in this case, where the patient clearly lacks the mental capacity to make the decision herself, it is right for the courts to decide based on her best interests." Conversely it was reported in the Telegraph that disability network, Radar had stated that this decision could be seen as a way of “deceiving and compelling [PS] into undergoing a procedure which she does not want”. Radar''''s chief executive, Liz Sayce, went on to explain that it was difficult to deny that receiving this treatment would be in PS''''s best interests, however such intervention could only be justified if it could be established beyond reasonable doubt that PS lacks the capacity to understand her prognosis if she does not have the operation. Sayce also explained that: “The right to refuse treatment is a cornerstone of human rights and medical ethics, but so too is the duty of care.” At the outset of his judgment Sir Nicholas Walls stated that this decision should be used as a basis which should be applied generally to the treatment of those who lack capacity under the Mental Capacity Act 2005, so this approach is set to become common practice in similar cases to come. http://www.mencap.com/news.asp?id=14944 http://www.telegraph.co.uk/health/healthnews/7768577/Woman-with-hospital-phobia-must-be-forcibly-treated-for-cancer-judge-rules.html