No more force (or threat of force) to compel feeding of woman with severe and enduring anorexia

By Elissa Novak and Brittany Murphy 4^th July 2025

Editorial Note (Celia Kitzinger):  The hearing took place over two days on 24^th and 25^th June 2025, and there was a shifting group of six or so observers, some of whom took part in discussion about the case which contributed to the ideas expressed in this blog post. I observed only the second day of this two-day hearing: I heard the judgment, and a detailed exchange about s.19 of the Senior Courts Act (in relation to the MCA and inherent jurisdiction) and its importance in progressing consistency in anorexia cases moving forward.  This legal discussion was technically too sophisticated for us observers to follow, especially as we do not have access to the “legal framework” document cited as an Appendix to the Trust’s position statement: that part of the hearing is not covered here. I am grateful to counsel for sending me their position statements and have drawn on them in editing this blog post to try to ensure accuracy. The blog is in two parts, written independently by two different observers, and reflects their perspectives on what they saw.  We understand there will be a published judgment and will add a link to it if so.

Update: The judgment has been published and it’s here (click on the live link): Re FF [2025] EWCOP 26 (T3)

No easy answers – by Elissa Novak

The Court of Protection rarely makes headlines, but it wrestles with some of the most difficult questions in law: autonomy, capacity, dignity and consent. For the protected person at the centre of these cases, its rulings can sometimes be a matter of life or death.

On 24 and 25^th June 2025, Mr Justice McKendrick presided over one such case (COP 20014975).

The protected party, FF, has a long-standing diagnosis of anorexia and Emotionally Unstable Personality Disorder (EUPD).  She was diagnosed aged 18 and has had multiple hospital admissions to try to treat her anorexia, including naso-gastric feeding and percutaneous endoscopic (PEG) feeding, involving significant restraint or force at times.  She is currently receiving treatment for her anorexia under s.3 Mental Health Act 1983, with a treatment plan that grants her extended s.17 MHA leave so she can return to her supported living placement for up to one month, before returning to hospital where she can (lawfully) be force-fed via a naso-gastric tube. All the parties (including FF’s father) agree that FF lacks capacity to make decisions regarding treatment for her anorexia (including specifically decisions about nutrition and hydration).

The Trust had applied for declarations and orders under the Mental Capacity Act 2005 that active treatment against FF’s wishes is not in her best interests upon her liability to be detained under the Mental Health Act ceasing.  In other words, treatment (including food and hydration) for her anorexia will no longer be forced upon her, and the ceiling of care is the point of her refusal.

I observed the first day of the two-day final hearing of FF’s case.  I understand that a judgment (approving the Trust’s application) was made on the second day,  and that it will be published. (A link to the judgment will be added to this blog post when it appears).

• The applicant NHS Trust (Leeds and York Partnership NHS Foundation Trust) was represented by Ms Emma Sutton KC. 
• The first respondent was FF by her litigation friend the Official Solicitor, represented by Ms Katie Scott.
• The second respondent was FF’s father, anonymised in accordance with the Transparency Order as “GG” was a litigant in person.

All parties supported the Trust’s application to stop the enforced treatment (and the threat of enforced treatment) which compels FF to take nutrition and hydration. It was before the court not because of disagreement but because (as the Trust put it) “the decision could be regarded as finely balanced, having regard, in particular,  to the dichotomy of [FF] not wanting to die, but equally being unable to take the necessary steps to ensure that she has an adequate calorific intake to sustain life”. 

 Even watching remotely, with occasionally patchy audio, the gravity of what was at stake was undeniable. This was not an adversarial case but a solemn one – attuned to the ethical weight of a decision that created the very real prospect that FF would die.

Mr Justice McKendrick, made it clear he wasn’t there to manage FF’s care or second-guess doctors. He zeroed in on two clear issues: “One is whether it is in FF’s best interests to receive medical treatment namely artificial hydration and nutrition administered by restraint or sedation… and on a full merits review do I agree or do I disagree with the responsible clinician not to impose treatment pursuant to section 63 of the Mental Health Act.”

FF has not consumed an oral diet for around 3 years.  She describes food, fluid and medication as “poison”, her current circumstances as “tortuous”, and forced feeding as being like “rape”. She does not consider herself to be unwell and does not believe that her weight is a problem.  She is frail and unable to walk long distances.  She is “unkempt”, believing that washing her hair and her clothes “adds to the calories”. She also considers that staff can transfer calories to her through their hands and asks that they wear gloves when touching her.

She wasn’t present in court, but in her absence we learned about her through the evidence of those who know her best. Her long-time treating clinician described her as, “Incredibly intelligent. She’s quite sarcastic and has a dry sense of humour. She always asks about me and how I am.” Her father spoke with pride and sorrow about the daughter he has seen both thrive and struggle. A young woman who had at one point stabilised her weight, lived independently, completed a university degree gaining a 2:1, and who actively sought help when she realised her eating disorder was re-emerging in 2021.  Her father’s reflection on that moment from 2021 may be the most quietly damning detail in this entire case. When FF went to her GP and asked for help, she was told her BMI was too high to qualify for a referral. For someone living with anorexia and emotionally unstable personality disorder, it was a devastating message. It not only denied her access to treatment, but confirmed the most dangerous cognitive distortion her illness reinforces: that she wasn’t “thin enough”. The impact was profound, it sent the message that help was conditional on further deterioration, and that care would only come when she was at her most unwell.

That moment, her father believes, marked the start of her steep decline. He spoke about how profoundly that decision had harmed his daughter and his hope that someone, somewhere, would revisit the guidelines that allowed it to happen. The impact of that moment echoed through the evidence of her treating clinician, who described how FF came to believe she had to be visibly unwell to deserve help: “She felt all of the difficulty she experienced was present because she was too ‘fat’… and that prevented her getting the support she required. So, she lost weight and deteriorated again to elicit the care that she had experienced previously.”

As FF’s condition worsened, her life was sustained through forced feeding via nasogastric and PEG tubes, sedation and physical restraint involving up to eight staff members at a time. These interventions were stark to hear described in court — invasive, relentless, and violent. Yet despite their severity, they had been only minimally effective. Over eighteen months of enforced treatment, FF’s weight increased by less than half a stone. Her treating clinician argued that the regime was not only ineffective, but actively traumatising. That whilst it kept her alive “I don’t think she has much of a life. I think her quality of life could be very different outside of that detention.”  This detention, she felt, had failed to address the core belief driving FF’s deterioration: that if she was “not seen as poorly enough” she would lose support. This resulted not only in physical deterioration but in a painful erosion of independence and life skills, with FF at one point needing her carers to hold cups to her mouth to help her to drink. This had created a situation where the care team felt “anxious” about responding to signs of improvement, in case FF saw this as a sign of recovery and a threat to the care, connection and safety she so desperately craves.

This cycle of coercion and fear was reflected, with painful clarity, in reports of FF’s own views, which spoke openly of suffering and a wish to die. But her treating clinician, echoing the view of FF’s father, urged the court to see beyond the surface of those words, saying: “ I don’t want to invalidate her distress in any way but …I don’t think she wants to die. I think she wants the torture to end and the fear to end but she doesn’t know how that can happen because of never experiencing anything other than forced treatment.”

Throughout her evidence the treating clinician was candid about the risks involved in ending enforced treatment but was firm in her belief that detention had become part of what was keeping FF unwell. Her proposal was not to withdraw care, but to redefine it, from something imposed on FF, to something shared with her. A way to prove that care will not vanish if she gets better. That her team will remain by her side, not because of a court order, but because she matters. As she put it, FF “has never experienced treatment of her own volition”. This, she believes, could be a turning point that allows FF to take charge of her illness and “experience those relationships outside of those restrictive frameworks”

The clinician also acknowledged a second, more painful possibility: that ending the use of the Mental Health Act might lead to rapid deterioration. FF could lose weight, disengage, and physically decline to the point of death. But even in that scenario, she held onto a thread of hope,  that reaching a point of crisis might prompt FF to decide she wants to live, and to seek help voluntarily, without force. In that version of events, treatment would not begin with restraint, but with consent and that difference, the clinician suggested, could be crucial to her long-term recovery.

This was not merely theoretical. The clinician pointed to past moments when, despite repeatedly expressing a wish to die, FF had at the brink, chosen life. In one such episode, she developed a serious fungal lung infection that required the removal of part of her lung. Faced with that emergency, FF actively engaged with treatment and gained weight. It was, the clinician argued, powerful evidence that when given space and agency, FF could recover not through compulsion, but by choice.

That same possibility had begun to show itself in quieter, more everyday ways. For much of her adult life FF has been detained under the Mental Health Act, subjected to repeated episodes of forced feeding, restraint, sedation, and fear. And yet, within that profoundly traumatising system, FF has developed relationships with carers, built not because of coercion, but in spite of it. Moments of trust, unmoored from calories or compliance, have allowed FF to express small but significant preferences. She has begun choosing the more calorific Pepsi Max over flavoured water, reading fashion magazines, watching Netflix, and asking to spend more time with carers in the evenings – brief glimpses of FF, slowly and tentatively, rediscovering herself.

After hearing submissions, Mr Justice McKendrick turned to the practical realities that would follow the removal of the Mental Health Act framework. He acknowledged the limits of his role, stating: “I’m not making a decision on whether she has capacity in respect of future medical emergencies.” But he pressed both barristers on what would happen if FF presented at A&E with a physical emergency, a broken bone, a cardiac arrest, and was unable to consent. Would clinicians have the authority to act? What if she asked to be restrained again? Would the law protect both her and those caring for her?

Both barristers agreed that the proposed care plan and draft court order needed clarification to ensure it could be lawfully and practically implemented. Responding to Mr Justice McKendrick’s concerns about ambiguity, particularly in emergency scenarios, they confirmed that revisions would be made. Ms Sutton, for the Trust, said the plan could be updated to reflect FF’s wish for all reasonable steps to preserve life, even if she were unconscious, and agreed to formally include a “pros and cons” guide already developed by FF’s care team. Ms Scott, for the Official Solicitor, supported refining the order’s language to align with the wording in the Mental Health Act, something frontline clinicians were experienced with which would allow them to make decisions about FF with confidence.

Throughout their submissions both Ms Sutton and Ms Scott kept FF’s humanity in view. Ms Sutton teased out the difficult legal arguments with precision whilst Ms Scott ensured FF’s voice was not lost in the process. Her questioning of the treating clinician drew out difficult truths about FF’s vulnerabilities, the scars of long-term care, and the desperate logic shaped by anorexia and EUPD, whilst holding onto the faint thread of hope her treating team are trying to protect.

The session ended with Judge McKendrick thanking the treating clinician and GG for their respective roles in FF’s life. He indicated he would reflect further on the wording of the order overnight and reconvene the next day to hear evidence from the medical expert. He invited any further submissions on ancillary issues, including clinician anonymity.

FF’s case offers no easy answers. It sits at the raw edge of law and medicine, where autonomy, trauma, and consent intersect in painful and unpredictable ways. I left the hearing with two strong convictions: that the current regime was doing more harm than good, and that stepping away from it carries a very real risk to FF’s life that in almost any other circumstance, would be unthinkable. I felt anger too, at the moment a GP told FF she wasn’t thin enough to access help and shared her father’s hope that out of this failure, someone will review the guidelines that allowed it to happen. What struck me most, though, was how aligned the parties were in their aims to find a better, more humane path forward. The question now is whether, in letting go of compulsion, the system might finally offer FF something closer to choice, dignity, and the chance of real sustained recovery.

Elissa Novak is a full-time carer for her son. She has previously published about another anorexia case here: Judge approves use of esketamine in anorexia case: Re CC She can be contacted via the Open Justice Court of Protection Project: openjustice@yahoo.com and is on X @ElissaNoves 

Evidence from the treating clinician – by Brittany Murphy

The treating clinician’s evidence was powerful and emotional. It was obvious that she cared a great deal about P, as her patient and as a human being. She remarked upon FF’s personality. She described FF as an empathetic and caring individual: she is someone who remembers snippets of information others tell her so she can ask after their lives. It was obvious that the clinician has a close relationship with P and is motivated by what is best for her. This was evident in her explanation of what would happen in terms of FF’s care going forward, and how she would remain a part of it in the way that she could to ensure stability for FF.

When asked questions in court her answers were exacting, and precise. She was clinical where necessary, but overall concerned to speak of FF not just as a patient, in terms of her illness and her treatment options,  but also of FF as a person, someone who has hopes and aspirations, and who has achieved a great deal with her life. The evidence cut to the heart of the matters before the court. She was able to describe the duality of FF in light of her illness in detail. The central problem is that FF’s wishes to refuse future treatments and her desire to live are contradictory in all of the evidence in the case.   The treating clinician also noted that although FF sometimes expresses indifference about dying,  when she is actually in at-risk situations she expresses fear of death. She also noted that P has made vast improvements in recent months, changes which for the ordinary person seem minimal but which are huge and which the clinical team intend to continue supporting.

Listening to the treating clinician speak about the case, was distressing because she so capably humanised FF, describing some of her interests, and showing a great level of care for for her, and her own distress at FF’s current situation and the decision before the court.  Sometimes in court, the people at the centre are presented with a necessary detachment. In this case where the decision could well lead to FF’s death no one shirked from the humanistic approach, instead celebrating FF for who she is and for the progress she has been made so far, whilst exploring the difficult decision of how best to proceed to “empower P in some way”.

And the judge’s compassion in this case, when speaking about FF, when delivering his judgement and in his interactions with those who care/know most about FF (family and clinician) was really note-worthy.  At times, he seemed a bit emotional and it seemed to me as if  he choked up at points and had to stop to regain his composure at various points: when describing FF’s qualifications,  how long she has been undergoing treatment, and at the end of his oral judgments at the end too when he was talking about balancing a best interest decision with the fact that the decision he made may be followed by FF’s death.

Brittany Murphy is a BTC and LLM student at Cardiff University with a keen interest in all areas of Health Law, including the Court of Protection, Clinical Negligence and Personal Injury. Her dissertation has a focus on vulnerable adults, the management of their finances, and the Court of Protection’s role in this. Brittany observes in the Court of Protection to gain a better understanding of this area of law.