A court system creaking under its own weight: Transparency challenges


by Daniel Clark
, 25th August 2023

Earlier this month (on Tuesday 16 August 2023), I was given an insight into the cracks spreading through the structure of the judicial system. 

This blog highlights those cracks, so that more people are aware of the pressure facing judges and, by extension, everybody else in the court system – from regional county courts to the Royal Courts of Justice. 

From Sheffield County Court…

It all started when I asked for the link to observe a hearing before HHJ Marson, sitting remotely in Sheffield. 

I asked for the link to observe this hearing because I had some previous knowledge of this case, having observed a hearing at the end of June this year. 

It caught my eye because Celia Kitzinger had tweeted about it from the Open Justice Court of Protection Project feed when she noticed it was incorrectly listed: it appeared in the Sheffield Daily Cause List rather than the Court of Protection list. It was only by chance that she’d looked at the Sheffield Daily Cause list, and so only by chance that we even knew this hearing was taking place. Celia tells me she also reported this incorrect listing to a Deputy Manager at His Majesty’s Courts and Tribunal Service (HMCTS) who said she would address this with the people responsible.  At the time she posted this, she didn’t know I’d observed a hearing in this case before.

When hearings are listed in Court of Protection list, would-be observers are instructed to contact the regional hub. As the hearing was in the Sheffield Daily Cause List, the instruction was to contact the Sheffield court directly. 

After some consideration, I decided to email the Sheffield court but copy in in the regional hub which, as a result of the last hearing (which had been listed correctly), I knew was the Leeds Hub. I cannot be sure which email resulted in a response because the response for my email (received at 09:45) came from the Sheffield Court of Protection email address. 

I was advised my details had been passed to the Judge and the Clerk and that they would join me to the hearing. The Transparency Order was also (unusually) attached. The hearing was listed to start at 10:30 but I still had not received the link at 10:40. I therefore sent a (polite) email asking whether there was some delay to the hearing getting started. 

At 10:50, having received no response, I rang the Sheffield Court directly, and the person I spoke to advised me to email them again so that my request could be sent to Sheffield’s Court of Protection team. I advised this was who I’d been in contact with so far but the person I spoke to advised me that this was the best option.  

At 11:11, I received a message from the judge (via the administration officer who sent me the Transparency Order) explaining that, ‘Circuit Judges in Sheffield are block listed at 10.30am. Just because they appear in the list at 10:30am does not mean that will be heard at 10.30am, I may not reach this case until this afternoon, I have too many other equally important cases to deal with at the same time.’ 

My first reaction was, if I’m honest, of frustration. I felt that the tone of the email was somewhat irritable, assuming that I should have some sort of knowledge about the way lists in Sheffield are composed. I also thought that it would have surely been possible for somebody I’d emailed or spoken to, to have made me aware that this hearing would not necessarily commence at 10:30am. 

I think it is also worth pointing out that the hearing at the end of June was also listed to start at 10:30am. On that occasion, I received the Transparency Order at 09:52, and the link at 09:58. In my opinion, it wasn’t unreasonable to except that would happen again. 

However, the tone of emails is very hard to judge. I’ve come across as short and irritable in email (I know because I’ve been told) when in reality I simply wanted to ensure information was passed on to somebody in a timely manner, when I didn’t have much time. 

In that light, I think this whole experience really demonstrates the way in which judges are expected to handle an increasingly high volume of hearings – as well as the demands of transparency, as exemplified by requests from would-be observers like me. We know about the volume of hearings: when we share listings on Twitter (aka X), we often have occasion to point out that some judges have multiple hearings listed for the same time, and so that inevitably some will start later than the listed time.

HHJ Marson is, of course, right to say that all cases are of equal importance. But every case has a diverse set of people involved, and every single one of them want to know about their own important case. 

I later found out that this case was vacated with consent orders in place. 

…to the Royal Courts of Justice

There was a hearing before Mr Justice Keehan that was also listed to begin at 10:30am that same day (Tuesday 16 August 2023).  I learnt from another observer that the start of that hearing had been delayed because the judge was involved with another matter. I therefore requested, and received, the link for this hearing, and joined the virtual waiting room. 

It was hard not to miss some similarities. Two cases, on the same day, were listed to start at the same time, only for the judge to be engaged in another matter, and the start of the hearing delayed. 

I knew, though I couldn’t see them, that also in the waiting room there must be lawyers waiting; lawyers who also have many other clients to make contact with, and other hearings to plan for. I thought there may well be professionals – a social worker, as it turned out – who were also anxiously waiting for the hearing to start, their diary already marked out as ‘do not disturb’ and facing the possibility of extending that period of not being available. 

And finally, I thought there may well be anxious family members, maybe even the protected party (P) herself waiting for the hearing to start. Although I could get on with other things, occasionally re-opening the tab to check I hadn’t missed anything, I highly doubted that they could switch between tabs with such comfort. For the hearing about you or your loved one to be delayed must be unbearable. 

Of course, this isn’t the judge’s fault at all.  He was apologetic (both at the start and end of the hearing) for the delay. In fact, it struck me again that this is an almost impossible situation for a judge to find themselves in: having to move with urgency from one hearing to the next, knowing full well how important each case is but inevitably having to keep somebody waiting.

Delay, delay, delay…

Both of these cases were, of course, dealt with by a judge on the day they were meant to be heard. However, it goes without saying that given the sheer volume of outstanding cases, there is delay elsewhere in the system too. 

It is not just public hearings that Court of Protection judges deal with. There are hearings that are private and others that are ‘closed’ (i.e. a party is being excluded, though all such hearings should now be listed).  There are applications for deputyship that must be approved by a judge, and applications for the deprivation of liberty where P is not living in a care home or hospital that must also be approved by a judge. 

The increasing number of people requiring a judge’s attention puts incredible strain on the judicial system: a system that is creaking under its own weight. Judges are expected to juggle an ever-increasing workload, as are the lawyers involved. Professionals feel the shockwaves of delays in the courts, and family members become even more anxious to see their loved one’s situation resolved.

And when we look past the judges and the barristers and the solicitors and the social workers and the nurses and the doctors and the anxious mother or worried uncle, we see P, the person at the centre of the case. When workloads are stretched and schedules would benefit from an extra couple of hours in the day, it is ultimately P who is left in limbo.  

Our focus, as the core team running the Open Justice Court of Protection Project, is of course on open justice and transparency.  We recognise the challenges the court faces in ensuring transparency – as well as everything else! –  in this context. It is to the credit of the Court of Protection that it continues to maintain its commitment to transparency as a fundamental principle, despite (or maybe because of) the pressures the system is under.  Our role is – and continues to be –  to support that judicial commitment to transparency.

Daniel Clark is a member of the core team of the Open Justice Court of Protection Project. He is  a PhD student in the Department of Politics & International Relations at the University of Sheffield. His research considers Iris Marion Young’s claim that older people are an oppressed social group. It is funded by WRoCAH. He tweets @DanielClark132.

Closed Material Proceedings: A ‘forced marriage’ hearing before Theis J

By Celia Kitzinger, 23 August 2023

The hearing (COP 13907545 on 27 July 2023) concerns a young woman in her twenties (M) who has a mild learning disability and can also experience anxiety, depression and impulsivity.  She needs 24-hour support to provide assistance with personal care, nutrition, medication and to allow her to access the community safely. 

In March 2022, M was moved from her parents’ home into supported living accommodation and the local authority (Luton Borough Council) made an application for personal welfare orders regarding her residence, care and support, and marriage.

In their application, the local authority described M as “a vulnerable lady who has entered into a marriage with her cousin” in Pakistan.  They said: “It is believed that her parents forced her to marry her cousin. M was previously living at home with her parents, who kept her locked in the house when they found out she is talking to a male friend”.  Divorce proceedings are now underway, and the parents are invited to file the Nadra Card providing final confirmation of divorce under Sharia law, with the court.

After 7 months in supported living accommodation, M returned home.  But just a few weeks later (in December 2022), she jumped from her first-floor bedroom window and sustained serious injury.  When she was admitted to hospital, her parents disguised how she had sustained the injuries (saying she had slipped and fallen in the snow in the garden), which led to M having an untreated fracture in one leg for nearly two weeks. 

On discharge from hospital, she was moved to a nursing and residential care home for rehabilitation. She’s engaging with physiotherapy and now (nearly 7 months after sustaining the injuries) is able to walk with a zimmer frame and crutches.  Her parents and younger sister visit her there, and she visited the family home recently to celebrate Eid – which went well. There are no restrictions on contact between M and her family 

M is currently subject to a Forced Marriage Protection Order (made by HHJ Hildyard).  This is an injunction preventing her parents, and her brother, from (amongst other things) forcing or attempting to force or otherwise instructing or encouraging any other person to force M to undergo any ceremony (or purported ceremony) of marriage, civil partnership, betrothal or engagement and from removing her from England and Wales.

The main issues before the court concern (1) M’s capacity to make her own decisions in the relevant areas; and (2) what best interests decisions should be made on her behalf in relation to those domains where she lacks capacity. The parties are not in agreement about the adequacy of the assessments before the court (made more than nine months ago) -which find capacity in some areas (including residence, contact, sex, and marriage, ) and not in others (including care and support).  There is a suggestion that her capacity fluctuates due to her anxiety and impulsivity.  There is also some concern about how she is affected by the “coercion and control” exerted upon her by her parents.

I’ve watched this case in court before – on 28 February 2023 (“A ‘closed material’ hearing on forced marriage”). On that occasion, PA reporter Brian Farmer also observed the hearing and wrote about it (“Arranged marriage: Judge protects woman with learning disabilities”).

A key issue to be resolved before the final hearing concerns redacted material in the court bundle – which had caused the judge considerable concern at the February hearing.

The parents, both of whom are parties to this case (as second and third respondents) do not have access to all the information available to the other parties and to the judge.  Some information has been redacted from the documents made available to the parents “because of certain matters M does not want discussed or disclosed to her parents”. I don’t know what that information is because it has also been withheld from observers.

At the last hearing, the judge was also unsure, on the basis of the paperwork before her, what the redactions were and hence what the parents did and did not know.

I’m unclear at the moment from the documents I’ve got what exactly has been seen by the parents.  I understand that certain parts of the information P has given has been redacted because of her concern about certain information being shared with her parents?  [Yes] I don’t know what has been redacted. It hasn’t been highlighted in the document and I think that is unsatisfactory…. I don’t think that was raised at the last hearing. I don’t know how much there has been discussion with the parents outside court so they know what all this means.”

At the end of the last hearing, she said: ” I’m minded to permit these redactions at the moment, but make it clear there is going to need to be some very rigorous thought and scrutiny of that before the next hearing.

So what happened at this hearing?

I watched the hearing from 11.16am when it started until the lunch break began at 1pm. I believe that the hearing continued in the afternoon, but I wasn’t able to observe then. So anything that was said or decided about closed material in the afternoon is not included in this blog post.

‘Closed material’ – the Guidance

The Court of Protection does have the power to withhold material in this way, but the starting point is that, in principle, all parties to proceedings should have sight of all materials upon which the court will reach its conclusions.  This is because:

  1. The principle of open justice, “fundamental to the dispensation of justice in a modern, democratic society,”normally requires that a judge cannot read or hear evidence, or receive argument which is not before all the parties to the proceedings;
  2. Securing the full participation of parties to proceedings, including by way of disclosure, not only enables them to present their case fully but also ensures that the court has the assistance of those parties in arriving at the right decision in relation to P’s capacity and best interests; 
  3. In any case where there is a suggestion that the court may in reaching its decision proceed on the basis of materials adverse to a party, both common law fairness and Article 6 of the ECHR normally requires that that party should be able to answer that material by way both of evidence and argument

This is taken from recent guidance available here (Guidance for the Court of Protection: ‘Closed hearings’ and ‘closed material’). For me, part of the value of observing this hearing was seeing how this Guidance (into which I had some input) played out in practice – and in relation to a very different set of facts from those that prompted my participation in creating the Guidance (see “New Guidance on closed hearings from the Vice President of the Court of Protection“).

The Guidance continues:

23. In any case where the basis for withholding disclosure is identified as being necessary to secure the rights of P, the following staged approach applies to the court’s consideration (and hence to the matters which must be set out in any application for material to be closed):

  1. When deciding whether to direct that a party should not be able to inspect the part in question, the court should first consider whether disclosure of the material would involve a real possibility of significant harm to P;
  2. If it would, the court should next consider whether the overall interests of P would benefit from non-disclosure, weighing on the one hand the interest of P in having the material properly tested, and on the other both the magnitude of the risk that harm will occur and the gravity of the harm if it does occur;
  3. If the court is satisfied that the interests of P point towards non-disclosure, the next and final step is for the court to weigh that consideration, and its strength in the circumstances of the case, against the interest of the other party in having an opportunity to see and respond to the material.  In the latter regard the court should take into account the importance of the material to the issues in the case;
  4. In all cases, the test for non-disclosure is whether it is strictly necessary to meet the risk identified by the court.

The July 2023 hearing

There had been some progress towards the “very rigorous thought and scrutiny” Mrs Justice Theis had asked for before the next hearing.

The position taken on behalf of M via her litigation friend the Official Solicitor (Emma Sutton KC of Serjeants’ Inn) is that the redaction of this information may be necessary to facilitate M’s full participation, and to promote her autonomy and independence.  This, she says, “trumps” the need for her parents to see all the materials.

A psychiatrist has been approached and offers a preliminary opinion that revealing this – currently redacted – information could lead to significant harm for M because of a risk of self-harm “if she feels unable to cope with negative emotions secondary to her family’s reaction”. 

The Official Solicitor is also looking at what steps can be taken by the care home staff to see if they could in some way be the conduit of the currently redacted information between M and her parents. It is (she said) “important to give M the tools to discuss the information currently withheld… We have been in discussion with the care home to see who would be best placed to support M with this”.

Acting for the local authority, Sally Gore of Fenners Barristers said that it was recognised that “to litigate, the parents are going to need this information”.  She also expressed concern that the local authority needs to build a good working relationship with the parents going forward and  “that is undermined by the fact that the parents know there’s information we have that we’re not sharing with them”.

The judge still seemed somewhat frustrated by the redactions and her impression was that “M believes she can keep these matters secret forever”.  She emphasised the need to have “open discussion with the parents, and at the moment, we can’t”. She said:  “The redaction issue needs to be grappled with before the next Case Management Hearing, with a view to the redactions being removed, so there can be meaningful discussion with the parents” – and in particular “the redaction issue needs to be dealt with before any placement options are approved by the court”. Returning home is one placement option; alternatives are either a Shared Lives placement or a supported living placement.

There is to be an in-person case-management hearing on Tuesday 17 October 2023 and a final hearing on 11-14 December 2023 (with a time estimate of 4 days).

It will be interesting to see how the issue of redaction has been handled.

Celia Kitzinger is co-director of the Open Justice Court of Protection Project. She has observed more than 470 hearings since May 2020 and written more than 100 blog posts. She is on LinkedIn (here), and tweets @KitzingerCelia

“I am very concerned … that the current situation is not tenable”: High-risk behaviour and questions about jurisdiction


by Daniel Clark
, 22nd August 2023

The young woman (AB) at the centre of this case (COP 12953545) suffered a Traumatic Brain Injury following a Road Traffic Accident some years ago. 

She is engaging in high-risk behaviour, and the local authority is seeking an order from the Court that it is in her best interests to be conveyed to a specialist unit for assessment. 

First, though, it must be established whether the Court of Protection has jurisdiction over this case. 

This hearing, which took place (remotely) on Wednesday 15 August, 2023 before Mr Justice Keehan, was in the urgent hearings list at the Royal Courts of Justice. The parties and their counsel were:

  • Conrad Hallin, of Serjeants’ Inn Chambers, representing the applicant local authority;
  • AB’s mother (the first respondent) who was representing herself as a litigant in person
  • Anna Datta, of Parklane Plowden, representing AB (the protected party) via her litigation friend, the Official Solicitor – as second respondent;
  • Francesca Gardner, of 39 Essex Chambers, representing the Integrated Care Board (ICB), the third respondent.

Background to the case
Very helpfully, and in accordance with the (former) Vice President’s advice (here), counsel for the applicant local authority offered to provide a background to the case, which was welcomed by the judge. 

He explained that following the accident, AB had spent some time in a neurological rehabilitation unit but, 18 months later, went on leave one weekend and refused to return. She was subsequently discharged.

In June 2021, she moved to rented accommodation with a support package amounting to 22 hours. In November of that year, a judge made a final order authorising her deprivation of liberty. 

In June 2022 she bought the property, and the deprivation of liberty was amended. Later, the local authority applied for a more restrictive package of care, which would entail an adjustment to the deprivation of liberty. 

Counsel for the local authority explained that ‘It was known [AB] was drinking a lot, inviting men to her house to have sexual intercourse, and wasn’t engaging with support staff’.” This escalation of high-risk behaviour prompted a Mental Health Act Assessment, wherein AB was assessed as not eligible for detention. Between May and August of this year, AB has been assessed several times.

AB’s behaviour has continued to escalate, with Counsel noting that “most recently I think it’s important to note that [AB] removed her own contraceptive implant which carries risk, it’s not medically advised that be done, and she’s also assaulted a support worker.” A specialist unit has been identified as a place that AB can move to for, initially, a period of 12-weeks of assessment. 

There was not any dispute that AB lacks the capacity to make this decision nor that it is in her best interests to move to this unit. However, Counsel for the local authority explained that, “there has been, it’s fair to say, some controversy about the status and the interaction between the Mental Health Act and the Mental Capacity Act in this case”.

The issue, in other words, is whether the Court of Protection has jurisdiction. 

The Mental Health Act and the Mental Capacity Act: An uneasy alliance

Counsel for the Local Authority submitted to the judge that the Court does hold jurisdiction, appealing to the judgment of Mr Justice Charles in the case of GJ v The Foundation Trust [2009] EWHC 2972 [Fam]. 

In that case, Charles J concluded that a decision-maker should, when considering whether to deprive somebody of their liberty, first accept the primacy of the Mental Health Act. Going forth, the decision-maker should assume that there is no alternative available under the Mental Capacity Act, and ask whether the person they are assessing could meet the eligibility for detention under the Section 2 or Section 3 of the Mental Health Act.

In this hearing, Counsel for the Local Authority submitted that, “in this case we have a situation where an assessment has taken place and [AB] has been found not to meet the criteria for section. It is very indicative that this patient is not within the scope of the Mental Health Act”. 

Having established (at least in the eyes of the local authority) that the Court has jurisdiction in this matter, the local authority was asking the Court to approve an Order that the move to the unit is in AB’s best interests. 

Given AB is “not in any way engaging” but that “there’s no way of managing that [risk] in the community”, the local authority also wanted approval for a draft transition and conveyance plan, including the possibility of the use of “restraint and chemical sedation”. This would be shared with both a private ambulance service and the unit. 

Following Counsel for the local authority’s submissions, the judge stated, ‘If I can just observe on the jurisdictional point, I’m inclined to agree with you and Mr Justice Charles. It would be absurd to know that a psychiatrist found her not to be detainable and yet the Court was still precluded from exercising its powers under the Mental Capacity Act 2005 to afford some protection to [AB] as this very vulnerable person”. 

The judge also acknowledged he had been to see AB the day before. He stated that, when he met her he learnt that “she feels though she has not been fully engaged in plans for her life ….I am concerned that [AB] has the opportunity to feel at least she has the opportunity to feel like she is planning for her life…She doesn’t accept that she needs help. Certainly she indicated to me yesterday, she doesn’t accept that she needs treatment, although she was urged to keep an open mind about a placement at [Unit]…But I am very concerned, as I think is the Official Solicitor and no doubt the local authority, that the current situation is not tenable.”

Counsel for AB via the Official Solicitor submitted that they were still awaiting instructions on the jurisdiction issue and the draft order. However, she did confirm that the Official Solicitor “has significant concerns about the vulnerability of [AB]”, and it is the Official Solicitor’s view that is in AB’s best interests to go to the unit identified. 

The judge also heard submissions from AB’s mother, who stated that the move “is not something I can see [AB] accepting….that’s like a zero to nothing chance.” However, AB’s mother explained that she wants “to get her back, to get her rehabilitation, to get her back into the community with support – how she was prior to the last 8-to-10 months”. 

I found this quite striking, and I thought at the time (and still do) that I cannot imagine the situation that AB and her mother are in. I have cared for people (in an inpatient setting) whose high-risk behaviour, whilst living in the community, placed them in dangerous situations, and resulted in moments of high anxiety for their families. They would often relay feeling as if their loved one has been ‘lost’, especially when the behaviour was so out of character.  

Counsel for the ICB also had limited submissions, agreeing with the consensus on best interests, and relaying that they will continue to support the parties as needed. However, “given the potential legal argument, I intend to say very little unless I can assist you, apart from this – it is not in my submission as straightforward as my learned friend suggests.”

Counsel made reference to the recent judgment of Mrs Justice Theis, Vice-President of the Court of Protection, in the case of Manchester University Hospital NHS Foundation Trust v JS & Others. In this case, Theis J commended the Official Solicitor’s suggested questions that should be asked in cases such as: 

“(1) Is P a ‘mental health patient’? 

(2) Is P an ‘objecting’ mental health patient? 

(3) Could P be detained under s 3 MHA 1983” [s48]

Counsel for the ICB simply made reference to this judgment and so the full position of the ICB on this matter remains to be seen. Whilst I did receive the ICB’s position statement, this was written at an earlier time, and does not acknowledge this issue in any great detail.

Similar to earlier in the hearing, Keehan J did state that “on a provisional basis, I would find it very unattractive that [AB] is not eligible for decisions made in the Court of Protection. Whilst she may not be judged to be detainable under the Mental Health Act, that may not be the same in the future. It leaves the question of what is to be done.” 

Given the fact that there is a sense of urgency in these proceedings, the judge decided to schedule another hearing for next week (week commencing 21 August 2023). At the very least, the “jurisdiction issue” will be dealt with at this hearing, as can what other evidence is needed for the formulation of a best interests decision.  

Transparency matters

Neither Celia Kitzinger nor I received the Transparency Order before this hearing, instead receiving it when the hearing was finished.

The purpose of a Transparency Order is to enable transparent reporting of Court of Protection proceedings.  This is usually achieved by permitting reporting but protecting the identity of the protected party (P), where they live, and the identity of carers and family members. It is usual to be able to name the public bodies involved in a case. After all, they are funded by the taxpayer, and cannot be accountable to the people who live in their area if they do things that go unreported.  

However, this Transparency Order (made by a different judge, Sir Jonathan Cohen, in an earlier hearing) extends further. It states that we cannot publish anything that “identifies or is likely to identify…any of the parties”. This goes far beyond protecting the identity of the protected party and her family. It means that we cannot name the local authority or the ICB. 

As she has done before (albeit much too often) Celia Kitzinger emailed the judge asking for the Transparency Order to be varied. She received an email not too much later, thanking her for her email and advising the judge is seeking the views of the parties. Hopefully, this can be addressed by the time of the next hearing.

Daniel Clark is a member of the core team of the Open Justice Court of Protection Project. He is a PhD student, funded by WRoCAH, in the Department of Politics & International Relations at the University of Sheffield. His research considers Iris Marion Young’s claim that older people are an oppressed social group. He tweets @DanielClark132.

“Not at risk of life and limb”: Room to breathe in a complex case


By Daniel Clark
, 20 August 2023

This case (COP 13043376) concerns Mr K, a gentleman with ulcers on both his legs, which he refuses to allow medical professionals to examine or treat. 

At a previous hearing, which law student George Palmer blogged about earlier (“Assessing and treating leg ulcers of a resistant patient“), Mr J McKendrick KC ruled it was in Mr K’s best interests to be assessed by the vascular team. Rather than be conveyed to hospital, it was ruled it was in Mr K’s best interests to remain at the care home in which he currently resides for this assessment. If necessary, chemical and physical restraint was to be utilised. The judgment for the previous hearing (Barnet Enfield And Haringey Mental Health NHS Trust & Anor v Mr K & Ors [2023] EWCOP 35 (15 August 2023) has already been published.

The hearing on 18 August 2023, a week after the last one, was to determine the way forward in Mr K’s best interests in the light of the assessment – and in light of the further expert evidence that was supposed to be ready for this hearing.

This hearing was listed to be heard before Mr Justice Keehan sitting (remotely) in the Royal Courts of Justice at midday on Friday 18 August 2023. It was a brief hearing – it began slightly late (at 12.12) and finished at 12.25.

The barristers representing the parties were the same as in the previous hearing: Arianna Kelly of 39 Essex Chambers, for the NHS Trusts; Simon Cridland of Serjeants’ Inn Chambers, representing Mr K via his litigation friend, the Official Solicitor; and Chiara Cordone, of 39 Essex Chambers, for the Local Authority.

Transparency matters

Access was challenging. I only got the link to this hearing at 11:55 – that’s five minutes before the hearing was listed to start. This is despite the fact that I sent my original request at 16:58 the day before, and then re-sent my request at 11:03 on the morning of the hearing. I also forwarded my request to a video hearings administrator whose email address I happen to have from correspondence about a different hearing. At 11:40, when I still hadn’t received the link, Celia Kitzinger forwarded my request to the person who had sent it to her. 

Obviously one of those courses of action paid off, though I can’t be sure which one it was – the link came from (what looked like) a generic email address. The delay isn’t actually anybody’s fault: it’s indicative of how busy the Court staff are. Transparency is a noble goal but for it to be fully realised, there must also be the infrastructure to support it. 

I have not been formally served with a Transparency Order for this hearing. Counsel for the NHS Trusts provided a detailed summary of the case so far but, unusually, she made no mention of a Transparency Order. In fact, nobody did. It struck me that, if there were observers new to joining hearings, they would not necessarily know that some information cannot be shared, and they would certainly have no way of knowing what that information was.

As it happens, Celia Kitzinger and I were (I think!) the only observers in this hearing, and from the hearing on 11 August 2023  (which Celia attended) we could reasonably deduce the Transparency Order would be the same. After all, if it had been changed, that would surely be raised in this hearing. Celia sent me the Transparency Order from the previous hearing before publishing this blog post.  

However, it is not crystal clear to either of us, having inspected the Transparency Order, exactly what information it is prohibited to report.  The “subject matter of the Injunction” (§6) says, as usual, that we can’t publish any information that identifies or is likely to identify (a) that Mr K is the subject of the proceedings, or (b) that any member of his family is the subject of these proceedings (in fact, no member of his family was a subject of the proceedings and it’s not known to the court that he has any family). At (c) it also forbids us reporting that Mr K is a party to the proceedings (that seems redundant, given (a)). And then (d) is a list of 7 other persons/organisations who can’t be identified: health and social care professionals involved in Mr K’s care, the care home he lives at, his GP and GP practice, the transport provider, and any witnesses (other than an independent expert witness).  The list of 7 prohibited pieces of information at (d) also prevents identification of “Hospital A” and “NHS Trust A responsible for Hospital A” but we don’t know which hospital or hospital Trust the injunction means to refer to here, since there are several hospitals and hospital trusts involved.  So we won’t name any hospital or any hospital Trusts (although some are named in the published judgment) until we receive clarification on this point. (There is “A Hospital” referred to in the judgment which “shall remain anonymous” (§87-89) – so presumably that’s the same as “Hospital A”.)

The hearing itself

Counsel for the NHS Trusts explained that Mr K was assessed by clinicians at the care home on 16 August 2023, a few days after the last hearing at which the judge authorised this. 

Although Mr K did not resist the administration of IM (Intra-Muscular) medication, the “care team [previously identified as an outside agency who can provide physical restraint] did hold his hands”. Mr K tried to cover his legs when he thought pictures were being taken of his legs but otherwise allowed them to be examined and re-dressed. 

The examination found palpable pulses to both feet and there was no cause for concern with the left leg. However, “his right leg is more swollen and is more painful and is described as having a malodour”. There was some discharge that could easily be wiped away. The vascular surgeon noted “the skin around the ulcer is not normal” which is potentially concerning given that cancer can develop with wounds such as this. 

The normal course of treatment would be admission to hospital for surgical debridement and biopsies. However, the consultant anaesthetist is of the view that general anaesthetic could be dangerous due to Mr K’s long-standing heart problems – it would “impose a realistic risk of death”.  Furthermore, given that Mr K “is not at risk of life or limb”, the consultants are convening a Multi-Disciplinary Team (MDT) meeting (scheduled for the afternoon after the hearing finished) to discuss the most appropriate way forward with a wide range of colleagues. 

In essence, this assessment of Mr K not being at immediate risk has allowed all parties a small space to breathe, which must surely have been welcomed in a case such as this. There has also been a delay in receiving the expert evidence (due by 4pm the day before) and there is a view that this evidence would be of benefit to the team making best interests decisions – another reason why some breathing space is welcome.

The apparent urgency of the situation has not, however, meant that decisions have been rushed. Alex Ruck Keene notes, in his analysis of the published judgment, that Mr McKendrick KC engaged in ‘careful examination’ and was concerned to test ‘each step on the restriction ladder’. With the intensity dialled down a little, the parties have even more time to test that ladder. 

The NHS Trusts were therefore not making an application (at this time) for Mr K’s conveyance to hospital or for compulsory treatment. Nor was it the view of the Official Solicitor or the Local Authority that conveyance to hospital would (at this stage) be in Mr K’s best interests. 

Instead, all parties were asking for the submission of further evidence, setting out the options available to Mr K and the risks associated with each option. This would include, should it be considered in future that it would be in Mr K’s best interests to go to hospital: a conveyance plan, a care plan for while he is in hospital, a palliative care plan should he deteriorate in hospital (“which is a risk”), and a plan for ongoing care in the community.

Counsel for the Local Authority indicated she had attempted to contact the care home manager for an update on Mr K’s presentation immediately after, and the days following, the assessment. She had been unable to reach him but offered to share the evidence with the other parties once she has done so. 

There was also a possibility raised that the care home manager has expressed concerns that the home could possibly not be able to continue to care for Mr K. This will also be pursued in the interim.

Brief reflections

Above all else, I was struck by the collaborative work that is being undertaken in order to ensure the best possible outcome for Mr K. I had the impression, as I often do, that all the parties were prioritising both Mr K’s best interests and his own wishes and feelings. 

I was relieved to hear that it hadn’t been necessary to physically restraint Mr K. As I have written for this blog before, physical restraint can be physically and emotionally demanding for both the person who is restrained  and for the staff. Any time it is planned for but avoided is a success.

Although I understand that some people may read that the staff “held his hands” as a euphemism for restraint, I imagine it is not. There were many times when, in my role as a carer supporting people who had been detained under the Mental Health Act 1983, I was involved in the planning of potential restraint for a person who had been outright refusing an intervention (often personal care) that was in her or his best interests. When safe and appropriate to do so, reassuring hand holding is a positive first step to take the ‘heat’ out of a situation. Sometimes, this comfort allowed a moment to be facilitated where the intervention could be carried out without the need for more restrictive holds. Where somebody did become suddenly resistive or aggressive, it would be easy to quickly and safely convert hand holding into a physical restraint. 

If you begin with out-and-out physical restraint, that means you don’t  give the person in question another opportunity to work with you.  Starting with restraint symbolises that you have gone into a room having already decided the outcome. In cases where behaviours that challenge can prevent interventions, it is important to maximise the choice available to somebody. 

This case will return to Court on Thursday or Friday of the week commencing 28 August 2023. Look out for it on our “Featured Hearings” list for how to observe it yourself.

Daniel Clark is a member of the core team of the Open Justice Court of Protection Project.  He is a PhD student in the Department of Politics & International Relations at the University of Sheffield. His research takes seriously Iris Marion Young’s claim that older people are an oppressed social group, and is funded by WRoCAH. He tweets @DanielClark132

Assessing and treating leg ulcers of a resistant patient: A law student’s first COP hearing

By George Palmer, 17 August 2023

Editorial note: The judgment has been published here: Barnet Enfield And Haringey Mental Health NHS Trust & Anor v Mr K & Ors [2023] EWCOP 35 (15 August 2023)

The person at the centre of the hearing I watched (Mr K) has chronic ulcers on both his legs. Medical professionals want to examine them and assess what treatment is needed.  Mr K is refusing to permit this. He has a long history of mental health challenges, going back at least to 2007, and he was diagnosed with severe ischaemic cardiomyopathy (heart failure) in 2014.  Previous medical opinion is that because of Mr K’s heart problems, it would be too risky to use physical restraint, or chemical restraint, to compel him to submit to examination or treatment against his wishes. 

I am a third-year law student at the University of York and I’m intending to go into Clinical Negligence as a barrister. I have always intended to go into the legal profession: its competitive nature and challenging environment are two of the many aspects that drive me towards the profession with the aim of pushing myself to achieve my best. I have always found healthcare law, which takes something so subjective and personal, such as a patient’s mental or physical health, and attempts to turn it into an objective matter and problem for barristers to debate over, and judges to determine, incredibly fascinating. And I feel that being a barrister, rather than a solicitor, gives me the best chance to make an impact on the decision-making process revolving around these patients and individuals. Although I’ve witnessed a variety of in-person and remote court hearings before, such as criminal trials in my local Magistrates Court, this was my first COP hearing and I found it highly intriguing.

I was keen to gain some real-world experience with health-related court cases, so contacted the Open Justice Court of Protection Project hoping to gain access to a medical treatment case. 

Transparency 

With the support of Celia Kitzinger, who was observing the same hearing, I sent an email to the Royal Courts of Justice staff, requesting access to observe the 3:00 pm hearing (COP 13043376) before Mr J McKendrick KC sitting at the Royal Courts of Justice on Friday 11 August 2023, remotely via MS Teams. 

I didn’t get a reply from the RCJ email address, but I forwarded my email to Celia who forwarded it on to a Video Hearing Administrator, who responded promptly by sending me the link. 

I’m not sure I would have gained access without the support of the Open Justice Court of Protection Project – either in terms of knowing how to go about finding a hearing to observe, or getting the link. The Open Justice Court of Protection Project allows aspiring barristers like myself the opportunity to observe and report on issues that I would never have had the opportunity to see without their help. Their dedication to the access of justice for all individuals, and their commitment to ensuring justice is open for all to observe, is something I am hugely impressed by.

There was an introductory summary at the beginning of the hearing which was hugely helpful to someone like myself, where this was my first encounter with the case, despite there having been multiple hearings in the past few weeks. It is now clear to me why the former Vice President of the Court of Protection, Mr Justice Hayden, placed such an emphasis on the importance of these introductory summaries, as they clearly do ‘help to place the identified issues in some context’, which he hoped they would. 

I have not been sent a Transparency Order for this hearing. One of the lawyers explained that there was a ‘standard’ Transparency Order (TO) in place – but as this was my first Court of Protection hearing I had no idea what this meant until Celia sent me a link to the ‘standard’ template. Although the judge mentioned that the standard TO allows for public bodies to be named, but not clinicians, upon further research and looking at this TO myself, I found that the anonymity surrounding COP cases and other healthcare law matters differed hugely from my experience of criminal trials. 

The person at the heart of COP hearings is someone who is deemed to have some “impairment of, or a disturbance in the functioning of, the mind or brain” (§2(1) Mental Capacity Act 2005) and it’s usual for their identity to be protected.  My research led me to the highly interesting criminal case of R (on the application of C) v Secretary of State for Justice [2016], where the court considered whether to grant anonymity to a mentally ill man convicted of murder. This case highlighted the importance that courts place on ensuring the reintegration of the mentally ill back into society, placing a large emphasis on the possibility that a lack of anonymity may result in the jeopardising of a person’s treatment, even where they have committed a crime. Therefore, from the unjust potential undoing of any treatment of a patient at the heart of healthcare cases, it is clear to see why so many are anonymised where most criminal cases are not, and the need for such anonymity within the Court of Protection. 

The barristers

The applicants, represented by Arianna Kelly of 39 Essex Chambers, were Barnet Enfield and Haringey Mental Health Trust and North Middlesex University Hospital NHS Trust.

The first respondent, represented (via his litigation friend the Official Solicitor) by Simon Cridland of Serjeants’ Inn Chambers, was the person at the centre of the case, Mr K. 

The second respondent, represented by Chiara Cordone of 39 Essex Chambers, was the London Borough of Enfield. I found via Google that Ms Cordone is a member of Freebar, a network dedicated to the inclusion and support of LGBTQ+ people within the legal community, which I find both an incredible and much-needed project within our current society.

The third respondent (also represented by Arianna Kelly) was the Hospital Trust. 

What was the hearing about – and what did the judge decide?

This was an application from two Trusts to find a way of assessing –  and subsequently treating – the long-standing ulcers  on Mr K’s legs. There was medical evidence that both legs might need to be amputated to save his life, in a worst case scenario.

Proceedings concerning Mr K go back a long time. 

In 2016 he was detained under section 2 of the Mental Health Act 1983, and prescribed antipsychotic medicine.

At some stage he was admitted into hospital and it would appear lived in hospital from around 2017 until he was discharged to B Home in March 2023, after Court of Protection proceedings, and with a standard authorisation in place depriving him of his liberty. 

However, once in the care home, “he spent almost all of his time in his room alone, declined any intervention from professionals and is not attending to his personal hygiene”.  

In July 2023 it was noted: “There are significant concerns regarding Mr K’s physical health, in particular the state of his leg ulcers which are reported to be in a concerning malodorous state” (§20 judgment)

On the 10th of July the applicants’ solicitor issued an application for an order to convey Mr K to hospital and for his ulcers to be treated.  The judge quotes from the grounds for the application.

Mr K is subject to a standard authorisation in a care home following five years spent in a mental health facility in which he was not detained but which he refused to leave. He suffers from persistent delusions and paranoia and refuses to engage with professionals. He has a long-standing heart condition which makes any treatment against his will extremely difficult to carry out. Previous orders of the Vice President Theis J have authorised his successful conveyance from hospital to a care home with provision for physical and chemical restraint – neither of which was in fact required. Mr K has longstanding leg ulcers which he has previously treated himself. He refuses to allow staff or other medical professionals to assist him or assess them. Staff at his care home are now concerned, however, that the wounds are foul smelling and may be demonstrative of significant infection: one staff member reports vomiting at the smell and seeing “bone” when dressings were removed. In light of the seriousness of the issues, reallocation to a Tier 3 Judge is considered necessary and appropriate.”

The key issue before the Tier 3 judge, Mr. J McKendrick KC,  is about the best way to assess Mr K’s potential health issues. 

Determining capacity

If Mr K has capacity to make his own decisions about his medical treatment, then his decision to refuse to allow professionals to inspect his leg ulcers is final. The court cannot order assessment or treatment of a person with capacity to refuse it.  

A person can only be deemed to lack capacity if they are unable to understand, retain, weigh or communicate information relevant to the decision that needs to be made, and if that lack of capacity is caused by an impairment in the functioning of their mind or brain. 

Both jointly instructed expert in old-age psychiatry and Mr K’s treating psychiatrist have given evidence that Mr K lacks capacity to make decisions about his treatment due to a delusional disorder or a severe (paranoid) personality disorder 

In determining P’s capacity, Mr. J McKendrick stated:

I am satisfied applying the statutory principles set out in section 3 of the 2005 Act that there is reason to believe that Mr K is unable to make decisions about the treatment options. I accept the written evidence of Dr M following his recent assessment that Mr K is unable to weigh the relevant information in respect of the treatment for his ulcers. This is largely because of his paranoid preoccupations and obsessions. Mr K is reported to be screaming at night in pain, yet will not permit a tissue viability nurse to assess his malodorous wounds. All the evidence points to there being reasons to believe he cannot make a decision for the purposes of section 3.” (§68 judgment)

He concluded, therefore, that “The court accordingly has jurisdiction to consider where Mr K’s best interests lie.” (§70)

Determining best interests

When a person is deemed to lack capacity to make a decision, the court must make it in their best interests.  A ‘best interests’ decision is not the same as the decision the person wants to make for themselves.  Here it is clear that Mr K does not want his legs to be assessed by professionals, but the judge made a decision that they should be assessed.

Doing nothing and allowing Mr K to go on in pain was, the judge said, “inhumane”. But taking Mr K  to hospital under sedation was too much of a risk for his physical health.  Therefore, the only option left to the court was to assess his leg ulcers in the residential home where he currently lives.

On 11th August 2023  (between court hearings) an overnight team of clinicians put together a care plan for his assessment. The judge notes that “They are much under pressure anyway, but particularly so as a result of the junior doctors’ strike. The clinical team trying to treat Mr K are operating in the most demanding of circumstances and have the court’s admiration and gratitude”. (§75, Judgment)

The plan contains detailed information how Mr K will be assessed by the vascular team, supported by others.  It is proposed to use very short-term chemical and physical restraint (if necessary) to ensure Mr K can be properly assessed, without causing the risks to his cardiac system or physical health that would arise out of longer-term restraint in an ambulance or in a long-term setting. This might include covert chemical restraint.

The judge said, “I am proceeding on the basis that Mr K doesn’t welcome this plan, and his wishes and feelings are against it, but we cannot permit further delay and it is overwhelmingly in his best interests”.

It is always uncomfortable to be in a situation where people are treated against their stated wishes – and even against their physical resistance.

One interesting feature of the hearing is that Mr K has what the judge described as “a strange view of authority”. Apparently, he is much impressed by the authority of the court, towards whom he displays “a degree of deference and respect, if I may put it that way”.  The judge suggested that “it may be that Mr K seeing the court order, and maybe a short letter from the judge saying, ‘I ask you to cooperate’ would be useful.  It might help to focus on his understanding why all of this is necessary and how worried we all are about him”.

Reflections

Considering I only observed the penultimate of many hearing, reading the judgment for context was incredibly helpful for gaining insight into the case. However, actually watching the hearing, live, in real time, and being able to listen to the barristers talk about the issues concerned gave the final outcome in the judgment lots more meaning and understanding than I am accustomed to when studying law and reading judgments for research purposes. 

Watching the advocacy skills of these established barristers and observing how a judge interacts with barristers, especially compared to my experience only with mooting which can be quite scary and harsh compared to this reality, was very insightful, and has given me more confidence that I will be able to go on and advocate in front of a judge with the same amount of skill and confidence as those within this case. Of course, one of the key differences in this case is that the Court of Protection is an inquisitorial – rather than adversarial – court, and the way that the barristers and everyone else were working together in the best interests for Mr K was very apparent.

This experience has been incredibly useful in giving me insight into the court – not only as to how barristers and judges interact and advocate in the Court of Protection, but also in  displaying the practical implications associated with a lack of capacity under the Mental Capacity Act 2005.  To see how deeply decisions about mental capacity can impact a patient’s life and the decisions that are made on their behalf was just eye-opening. 

The final hearing on Friday 18th August 2023 is to determine the way forward in Mr K’s best interests in the light of the assessment that this hearing authorised – and the further expert evidence that will be prepared for that hearing.

I would highly encourage law students to observe this hearing tomorrow  – and other hearings in the Court of Protection.  It is a great opportunity to see how the provisions and materials we learn about in our studies really affect people in a court of law.

George Palmer is a third-year University of York Law student and aspiring Clinical Negligence barrister. He hopes to commence Pupillage in 2025 and one day become a leading barrister in his chosen field.

Is he deprived of his liberty? (Plus a request to vary the reporting restrictions – again)

By Celia Kitzinger, 15 August 2023

This is an unusual  s.21A challenge to the authorisation of Mr P’s deprivation of liberty.

The only issue for determination is whether or not Mr P is actually “deprived of his liberty”.

If he is, one of the key safeguards of DoLS is that he will continue to be entitled to non-means tested legal aid. If not, he will lose that safeguard, including his legal representation, as he doesn’t qualify for means-tested public funding.

Background

The case (COP 14094320) was heard remotely by District Judge Bell, sitting in Leeds Combined Court on 7 July 2023.  Lawyers were in court to represent Mr P (Neil Allen), Leeds City Council (Sara Townend), and – newly joined to the case – the Integrated Care Board (Ben Troke).

About a year ago Mr P suffered a severe cardiac arrest – completely “out of the blue”.  He is in his forties. His wife gave him cardio-pulmonary resuscitation and an ambulance was called. He had six shocks and return of spontaneous circulation was achieved after a downtime of 29 minutes. He was admitted to hospital and diagnosed with a resulting brain injury. 

Since Mr P’s discharge from hospital, the Integrated Care Board (ICB) has commissioned a place for him in a care home for neurorehabilitation. 

Two standard authorisations for his deprivation of liberty have been granted, most recently on 1 June 2023. Leeds County Council is the named supervisory body  for the purposes of these two standard authorisations.

Mr P is now spending weekends with his mother, but living at the care home 9am – 4pm for four days a week. This is a shared care arrangement, with a view to him transitioning to live with his mother once rehabilitation is complete.  (His wife has started divorce proceedings.) 

The question raised by the Local Authority as a supervisory body was whether Mr P is still deprived of his liberty, and if so whether that should be authorised by them, or whether the court should authorise the arrangements in their entirety.  

What does “deprivation of liberty” mean?

When considering if a person’s care arrangements amount to a deprivation of liberty, the case of Storck v Germany (2005) 43 EHRR 96  established that there are three broad components to consider: 

(a) the objective component of confinement in a particular restricted place for a not negligible length of time; 

(b) the subjective component of lack of valid consent; and 

(c) the attribution of responsibility to the state. 

In P v Cheshire West and Cheshire Council [2014] UKSC19, the question of what amounts to a deprivation of liberty was considered further.  Lady Hale described an “acid test”, setting out that a person is said to be deprived of their liberty if they are subject to “continuous supervision and control” and are “not free to leave” (§54). Lady Hale also held that “we should err on the side of caution in deciding what constitutes a deprivation of liberty” because of the vulnerability of the people involved.

Is Mr P deprived of his liberty?

On behalf of Mr P,  Neil Allen (via his litigation friend, Accredited Legal Representative, Alison Kaye) takes the position that Mr P’s care arrangements constitute a deprivation of liberty because:

  • The unit doors are locked
  • Mr P has constant staff support in place and cannot leave the unit apart from arranged overnight periods during the week and “weekend leave” with his mother, as he is vulnerable to possible harm and exploitation of others
  • Others have decided that he is permitted to spend overnights and weekends at his mother’s home
  • He is required to return to the care home for four days per week between 9am and 4pm
  • If he did not return for a long time, the police would be involved to bring him back to the care home
  • The care home continues to be fully funded so that, if necessary, Mr P can be required to return to spend overnights and weekends there
  • Staff support and prompt Mr P with activities of daily living and assist him with managing his behaviours and activities.
  • Staff manage and administer medications in his best interests
  • Staff monitor his condition throughout daily activities and record this
  • He is not free to leave to live where he wants and has, on occasion, been returned by the police.
  • He is not able to manage his own finances.

I think (but don’t know for sure) that Leeds County Council (LCC) must previously have considered that Mr P was not deprived of his liberty.  I think this because the judge made reference to their “current position” (implying a different earlier position) and Neil Allen (for Mr P) said in response that he was “breathing a sigh of relief” – which also suggests that LCC has shifted their position towards his own.  The position statement from LCC doesn’t make reference to any change in their position but simply states that  – erring on the side of caution –  it may be considered that the care arrangements for Mr P do amount to a deprivation of his liberty.  The evidence cited for this position is that Mr P is prevented from leaving the placement between 9am and 4pm, and when he is not present in the placement he is under the supervision of his family at all times. He is deemed to lack capacity to consent to these arrangements (due to his brain injury) and the care arrangements are the responsibility of the state, given that the care plan is commissioned and reviewed by the ICB. 

Parking the “deprivation of liberty” issue

Both parties were content, now, to “park” the question of whether Mr P is properly described as “deprived of his liberty” (and if he is, how that should be authorised) for a next hearing.  Counsel for P said “this may fall away as an issue if and when he is discharged from the care home in September”. 

The judge said she was not in a position to decide today whether or not Mr P was deprived of his liberty, and discussion shifted to other matters.

There are questions about where Mr P is “ordinarily resident”, a need to assess his eligible needs under the Care Act, and arrangements are required for Mr P to meet the judge – face-to-face, as he would prefer.  

The date of the next hearing was set for 2.00pm on 11 October 2023 for two hours. The hope is that, by then, Mr P will be living full-time with his mother and this “might be a final hearing if everything goes according to plan”.

And finally….. Varying the Transparency Order

This was yet another case in which the Transparency Order had been drawn up specifically to prohibit reporting of the name of the Local Authority (Leeds County Council)  in this case (but not the name of the ICB).  

As soon as I received the Transparency Order I checked §6 and found this:

(6) The material and information (the Information) covered by this Injunction is:

      (i) any material or information that identifies or is likely to identify that:

           (a) P is the subject of these proceedings (and therefore a P as identified in the Court of 

                 Protection Rules 2017) or that

            (b) any person is a member of the family of the subject of these proceedings (namely 

                  P), or that 

             (c )  A Local Authority is a party to these proceedings, or that

             (d)  any material or information that identifies or is likely to identify where any 

                    person listed above lives, or is being cared for, or their contact details.

This paragraph is a poorly edited version of the standard template (§ (6)(i)(d) above makes no sense and should have been (6) (ii)). But the key problem is (6)(i)(c) which prevents reporting the name of the Local Authority (or apparently even the fact that there is a Local Authority as a party to these proceedings, though this cannot have been the intention!).

This was an unusual case insofar as I’d been sent the Transparency Order in advance of the hearing (at 9.57am, along with the video-link from the court administrative officer).  The hearing was listed to start at 11.00am, though in the event it didn’t begin until 11.47am: the judge said she’d been “double-listed, and then I was not able to join the link”).  

At 10.35am, I sent this email to the CoP-Leeds email address from which I’d received the Transparency Order and the video-link.

Celia Kitzinger is co-director of the Open Justice Court of Protection Project. She has observed more than 460 hearings since May 2020 and written more than 100 blog posts. She is on LinkedIn (here), and tweets @KitzingerCelia

Varying reporting restrictions to name Kent County Council in “shocking” delay case

By Celia Kitzinger, 11 August 2023

Kent County Council was criticised in court for misunderstanding the law and creating lengthy delays for a care home patient who wants to move to a different care home closer to his family[1]

Mrs Justice Theis, Vice President of the Court of Protection, said in the course of a hearing on 5 July 2023 that the delay had been “shocking” and that she felt “despair” about the way the case had been handled.

Mr N, who has schizoaffective disorder, has been in the care home for nearly three years, since being discharged from hospital. He issued an application (via his litigation friend the Official Solicitor) challenging his deprivation of liberty in November 2022.

Article 5(4) of the Human Rights Act states that: “Everyone who is deprived of his liberty by arrest or detention shall be entitled to take proceedings by which the lawfulness of his detention shall be decided speedily by a court and his release ordered if the detention is not lawful”.

But nothing has been happening “speedily” in this case.

The judge said: “It’s shocking, frankly. Here we are 8 months later, effectively having the first hearing”.

What did Kent County Council do to contribute to delay?

Until shortly before the hearing, Kent County Council (KCC) said  – wrongly – that the Court of Protection couldn’t make any decisions about Mr N because the court had no jurisdiction.  

The KCC said that because Mr N is a ‘restricted’ patient (under s.37 and s.41 Mental Health Act), the application should have been made instead to a Mental Health Tribunal. 

The lawyer for Mr N (Bridget Dolan) said: “KCC’s position on jurisdiction is quite simply untenable, with no basis in law”. She also said that KCC had “misunderstood” some of the facts of the case and that, as a result, the application had gone “horribly awry”. 

Kent County Council seems to have recognised, at the eleventh hour, that they had got this wrong.  Shortly before the hearing they accepted that the Court of Protection does have jurisdiction and can make a decision about where it is in Mr N’s best interests to live.  

Bridget Dolan (for Mr N) explained that “At the pre-hearing Round Table Meeting, we put to KCC that we considered [their application] misplaced. It has now been withdrawn.  KCC accepts that the court does have jurisdiction… The issue of the jurisdiction of the court has now fallen away completely.  

When Ms Dolan explained this to the judge in court, that was the closest I’ve ever got to seeing a judge roll her eyes, displaying apparent exasperation.

The judge identified other causes of delay in this case. A  hearing listed for March 2023 never happened – the judge later said “there are lessons to be learnt about vacating hearings in such a vague and incoherent way”. There was a delay in transferring the case up to a Tier 3 judge because there was no fixed date for a hearing (only “first open date after …”).  And because Mr N says that he has capacity to make his own decisions about residence, an expert witness was needed in addition to the s.49 report – an expert had been identified, but the capacity assessment had not been progressed, since it might not have been needed if KCC was right about the jurisdictional issue – and the expert was now unavailable for a month).  Overall, “the effect of KCC’s application to dismiss proceedings was everything was put on hold” (Official Solicitor). 

According to the Official Solicitor (acting for Mr N), progress was “delayed for many months by KCC’s application for dismissal”. Her position is that the delay is “a breach of Mr N’s procedural right under Article 5(4) to a speedy determination of the lawfulness of his continued detention. That delay may well now sound in damages once KCC’s application is dismissed[2]

The judge will hear this case again in October 2023, after an expert report on Mr N’s capacity has been obtained. Mrs Justice Theis has decided to reserve it to herself “so that I can understand how this delay has come about.  It is not a good reflection on the system that a challenge was made in November 2022 and here we are in July 2023 without a determination and with a three-month delay”.

Naming Kent County Council

It’s in the public interest to know that a public body has acted in this way.  People who pay their council tax to fund Kent County Council have a right to know when it is subject to criticism in a public courtroom.  Generally, there is no prohibition on naming public bodies when we report on Court of Protection hearings.

But in this case, it turned out that publishing information about the identity of the County Council was prohibited under the terms of the Transparency Order.

I didn’t know this when I was watching the hearing, and I wasn’t sent the Transparency Order until after the hearing had finished.

What is a Transparency Order?

The Transparency Order is an Injunction (a court order) telling us what we are not allowed to tell anyone about a case in the Court of Protection.

If we disobey, we may – as it says in bold on the face of the order – be found guilty of contempt of court and may be sent to prison, fined, or have our assets seized.  

There is a standard template for Transparency Orders in the Court of Protection and §6 covers the “subject matter of the injunction” i.e. the things that cannot be publicly reported.  The main restriction relates to the identity of P (the person at the centre of the case) and their family.  Paragraph 6 of the template forbids us from revealing:

The form of the standard order in this case reads as follows:

The standard template also says (at §10) that anyone affected by the order (which includes observers) can ask for the order to be varied or discharged.

Asking to vary a Transparency Order (in court)

The most straightforward and time-efficient way for observers to raise concerns about the reporting restrictions imposed upon us in Court of Protection hearings is when we are in court during the hearing.  

I’ve done this dozens of times and it’s usually been resolved within two or three minutes.  

It generally runs off something like this:

Judge: Have you seen and understood the Transparency Order?

Celia:  Yes, but I’d like to ask for it to be varied. It’s not clear to me why the (Local Authority/Trust/ICB/Health Board) is included in paragraph (6) in the list of information that we’re not allowed to make public. This is a public body, paid for with our taxes, and should be publicly accountable for its actions.  In terms of the Article 8 (privacy) and Article 10 (right to freedom of information) balance, is there an argument that revealing the name of the public body makes it likely that P could be identified? 

Judge:  (after short faff while everyone locates the Transparency Order and the relevant paragraph) Can I have counsels’ views on this.

Counsel for P, public body and other counsel:  (all looking at Transparency Order as if they’ve never seen it before) There’s no reason to protect the identity of the public body. Publication of the identity of the public body will not realistically lead to identification of P.

Judge: In that case I will vary the Transparency Order.

That didn’t happen in this case because I didn’t have the Transparency Order until after the hearing was finished, so I didn’t know that there was a reporting restriction covering Kent County Council. 

I had asked counsel for the Transparency Order (and their Position Statements) via email while we were all on the video-platform waiting for the hearing to begin.  It was due to start at 10.30am but was delayed (until 11.14am) due to “technical difficulties” with an earlier hearing.  Before the hearing started,  I emailed my requests to the barristers I could see on screen – at 10.51am (Bridget Dolan), 11.02 (Steven Broach) and 11.05 (Michael Paget). 

Virtually the first thing the judge said on joining the platform was that there was a Transparency Order in place which “prevents anybody from naming or identifying the person who is the subject of the proceedings, directly or indirectly”.  She did not mention any prohibition on naming Kent County Council, nor did she direct that the Transparency Order should be sent to observers.  Instead, she said, “if anybody who has joined the hearing would like to see the Transparency Order, they can ask the court for it”.  The hearing ended at 12.25pm and the Transparency Order was sent to me more than three hours later (at 3.43pm).  

So, it was only much later that day, after the hearing was finished, that I realised I was prohibited from naming Kent County Council.

Asking to vary the Transparency Order after the hearing is finished

The delay in sending me the Transparency Order meant a much more cumbersome and time-consuming process both for me and for the lawyers and judges when I decided it was necessary to ask for the Transparency Order to be varied. 

Here’s what happened next.

Wednesday 5th July 2023 (the day of the hearing)

I sent an email to Mrs Justice Theis (via her clerk) at 8.17pm.

Thursday, 6 July 2023

8.16am: Mrs Justice Theis (via her clerk) asked for representations from counsel. The judge’s clerk copied me into an email asking the Official Solicitor and Kent County Council to provide written responses to my request for the Transparency Order to be varied  by 11am that day.

10.09am: The Official Solicitor said she supports the principle of transparency in respect of these proceedings and perceives no realistic risk of jigsaw identification of Mr N should the local authority be identified in this case. The OS therefore raised no objection to my application to identify Kent County Council as the relevant local authority. 

11.57am: Kent County Council has not responded and the matter is passed to a different judge. We were sent an email from Mr Justice Poole’s clerk explaining that Mrs Justice Theis was no longer available to deal with this matter so Poole J would deal with it instead.

Friday 7 July 2023

10.20am: The solicitor acting for Kent County Council says she is urgently seeking instruction and says she’ll provide a response by the end of the day. (She doesn’t.) 

Monday 10 July 2023

2.14pm I email the judge’s clerk to request a decision from Poole J

2.26pm: The solicitor acting for KCC emails to say that KCC do not raise any objections to being identified as the relevant local authority.

2.44pm: I email Poole J’s clerk: “Further to the email […] saying that KCC do not raise any objections to being identified as the relevant local authority, I assume that Poole J will now make an order to vary the TO to permit this?”

Tuesday 11 July 2023

11.10am An email from Poole J’s clerk informs me that an order is now being drawn up to permit the naming of Kent County Council as respondent to the proceedings.

12.33pm: I receives an order which says:

 “UPON receiving an application by Professor Celia Kitzinger of the Open Justice Project  [sic] to be permitted to name Kent County Council as Respondent to the proceedings

AND UPON the Court determining that there should be no restriction on reporting the name of Kent County Council as Respondent to the proceedings

By consent of the parties

IT IS ORDERED THAT

1. The Transparency Order dated 4 November 2022 shall be varies (sic) as follows:

     (i) Paragraph 6(c ) shall be deleted.

     (ii) There shall be added as paragraph 9(1)(f), “naming Kent County Council as Respondent”

So, the deleted paragraph is the paragraph that says I’m not allowed to identify Kent County Council as a party to the proceedings.  And the new paragraph that has been added is under a heading that reads: “What the Injunction does not prevent people from doing and does not apply to”.  So it means that the injunction now does NOT prevent me from naming Kent County Council.

Reflections and outcome

This was all quite a palaver – especially compared to the straightforward way in which this issue can be dealt with in court if the Transparency Order is made available to observers in a timely manner.

If I’d had the Transparency Order during the hearing on the morning of 5th July, I’d have been able to request the variation at that point, and would have been able to write a blog post or tweet or any other kind of public report naming Kent County Council in connection with this case on the same day.  Instead, I had to wait nearly a week –  until the afternoon of Tuesday 11 July 2023.

Because I wasn’t able to ask for a variation in the order until after the hearing was finished, my request involved a fair number of busy people in a lot of extra work, as well as causing a delay in the implementation of open justice.

It is testimony to the commitment of lawyers and judges in the Court of Protection that at no point did anyone say – or even hint –  that I was being a nuisance or that my request was unwelcome.  

And at a subsequent hearing before Mrs Justice Theis a few weeks later (COP 14081834, 1 August 2023), I was pleased to hear her say: “If anybody needs a copy of the Transparency Order, they should contact the court immediately, or if there are any queries once they have seen it”.   Of course, most people don’t know how to “contact the court” (emails to the RCJ court staff or to video-hearing administrators rarely work for obtaining Transparency Orders).  I emailed one of the barristers, Leonie Hirst, and received the Transparency Order at 11.07am, i.e. around half an hour into the hearing.  At 11.12am, I emailed counsel and the judge’s clerk:

Please could it be brought to the attention of the judge that I would like to propose a variation to the TO which currently protects the identity of the Newcastle upon Tyne Hospitals Foundation Trust, which is a public body. It’s unusual for us to be required to conceal the  identity of public bodies – paid for by our taxes and publicly accountable for their actions.  I note the TO does not explicitly cover Newcastle City Council.  Is there any real likelihood that identifying the Trust will lead to identification of P? If not (and on my understanding of the case it seems unlikely) then I would like to request this variation please.”

The judge dealt with my request at 11.44am, during a pause in the substantive proceedings during which one of the witnesses, P’s lead support worker,  had been asked to log off to read an attendance note which (it seems) should have been sent to him and had not.  The judge asked counsel whether there were any “compelling reasons” for preventing me from naming the Trust (or the City Council) and was told there were none. She then immediately asked for a revised version of the Transparency Order to be sent to her to reflect that.  That felt much more proportionate!  

The question remains, of course, as to how it is that these Transparency Orders are being drafted, and signed off by judges, in such a way as to ban the naming of public bodies – when in my experience there is rarely any good reason for this, and requests for variations are regularly granted unproblematically.

By including the names of public bodies as the subject matter of an injunction against us, the Court of Protection limits transparency – often, it seems, for no good reason.  It’s frustrating for me to receive blog posts from people who’ve observed hearings I haven’t attended and to see, when I ask for their Transparency Orders, that they prevent publication of the names of public bodies in quite “routine” cases.  In many (most) cases, I strongly suspect that if I’d been in that hearing and asked for that Transparency Order to be varied, it would have been. But, of course, it’s not fair to expect people (often students) observing their first COP hearings, to know that this is something to raise with the judge – or indeed to expect them to know how to go about doing that. Few observers (even journalists!) have the confidence and skills to raise questions about Transparency Orders.

I would like to see the lawyers who draft Transparency Orders and the judges who sign them take responsibility for checking that they’re compliant with the court’s Article 8 and Article 10 obligations, i.e. that they represent a considered balance between respect for P’s privacy and the right of the public to freedom of information.  

It’s very rarely the case that knowing the name of a public body will lead to identification of P, or P’s family.  

There’s an important general principle that we should be able to hold public bodies to account – especially in cases like the one reported here.

The presence of public observers in the courtroom is not enough, in and of itself, to deliver on the judicial commitment to transparency if we’re banned from reporting the names of public bodies for no discernible reason.  

Postscript

For an update on this case, and the judge’s decision in the substantive matter of Mr N’s deprivation of liberty, see the blog post about the October hearing of this case (“Another case of s.21A delay (with a happy ending)“which I also observed. Regarding the Transparency Order, in their Position Statement for the October hearing, the Official Solicitor records as follows (at §5):

“The order of Poole J made on 11 July 2023 varied the transparency order of 4 November 2022 to remove the prohibition on naming KCC as respondent (following an application by Professor Celia Kitzinger) [D80-81]. Regrettably, on review of the file by Mr N’s solicitors, it has come to light that this was an error on the template of the order filed with the initial application, and anonymisation of KCC should not therefore have been included in the order. This was not picked up by the parties until this was pointed out to the court. Mr N’s solicitors will ensure this is not repeated in any further cases.”

Celia Kitzinger is co-director of the Open Justice Court of Protection Project. She has observed more than 460 hearings since May 2020 and written more than 100 blog posts. She is on LinkedIn (here), and tweets @KitzingerCelia


[1] For another blog post about this same hearing, dealing with the substantive matter of the application, see A s.21A challenge for a ‘restricted’ patient: A “shocking” delay.

[2] Taken from the Official Solicitor’s Position Statement (4th July 2023).  The case law cited on this point is R (KB and Others) v Mental Health Review Tribunal and Secretary of State [2004] QB 936.

A s.21A challenge for a ‘restricted’ patient: A “shocking” delay

By Febienne Green (with Celia Kitzinger), 8th August 2023

On Wednesday, 5th July 2023, I watched a hearing (COP 13627234) before Mrs Justice Theis, Vice President of the Court of Protection, sitting at the Royal Courts of Justice via MS Teams.  

The case was a s.21A challenge to a standard authorisation depriving Mr N of his liberty in a care home.  He filed his application in October 2022, and the judge was very critical about the delay in this case and criticised the lack of “robust management”: “It’s shocking, frankly. Here we are 8 months later, effectively having the first hearing”.[1]

This is an unusual case because Mr N is a ‘restricted’ patient, conditionally discharged under section 37 and 41 of the Mental Health Act 1983.

Under the Mental Health Act 1983, the Crown Court may impose a hospital order together with a restriction order upon a ‘mentally disordered’ offender, if this is considered necessary to protect the public from serious harm.

This means that the patient is liable to indefinite detention in hospital for medical treatment and can only be discharged by the Secretary of State for Justice or the First-tier Tribunal. Such a discharge can be conditional, which means that the patient remains subject to recall to hospital, as well as to whatever conditions are imposed by the Secretary of State or the First-tier Tribunal.

In the case of Mr N, his warrant of conditional discharge requires Mr N to reside only at X Care Home and not to move residence “without the agreement of the community team who must notify the MoJ [Ministry of Justice] at least 14 days in advance of such a move”. 

It is settled law that the Mental Health Act 1983 does not permit either the First-tier Tribunal or Secretary of State to impose conditions amounting to detention or a deprivation of liberty upon a conditionally discharged restricted patient if that patient has capacity to make their own decisions about residence and care (Secretary of State for Justice v MM [2018] UKSC 60 [38]). However, when someone is said to lack the requisite capacity, they may be given a conditional discharge to a place of residence where the circumstances amount to a ‘deprivation of liberty’ if (but only if) that deprivation of liberty is authorised under the Mental Capacity Act 2005.  That’s how it’s come about that Mr N lives at his current care home. 

Mr N’s deprivation of liberty is therefore authorised under the Mental Capacity Act 2005, and it is that standard authorisation that he now seeks to challenge. 

This was a complicated and unusual case for my first hearing! Luckily, Celia Kitzinger also watched this hearing and was able to support my understanding and reporting of this case.  She also benefitted from receiving both the Position Statement from the Official Solicitor and the Transparency Order.

My interest in observing a hearing 

I studied law and completed the Bar Training Course with an ambition to practice in clinical negligence after witnessing the effects of a brain injury on my younger sister and the clinical negligence case that ensued. During university I studied healthcare law, mental health law and disability law. It was the study of disability law that introduced me to the Court of Protection. I was fascinated by the importance of the issues dealt with and the profound effect these decisions have on an individual (some of whom are the most vulnerable people in society), their family and society, all set within a legal process.

Access to the hearing 

I first became aware of this hearing when Celia Kitzinger of the Open Justice Court of Protection Project emailed the details of this hearing to me and recommended I observe it.  

In my search for access to the hearing, I began by emailing the Royal Courts of Justice (RCJ) at 8:19am. When I did not receive a response, I sent another email labelled ‘URGENT’ at 9:58, whilst simultaneously telephoning the number provided for enquiries relating to hearings at the Royal Courts of Justice. However neither my email, nor my phone call, was answered.  

I emailed Celia Kitzinger regarding my struggle to gain access to the hearing. She forwarded it to a number of people to assist in my search for the link. I was subsequently sent the hearing link and advised that the hearing was likely to start late. 

Following this, the Open Justice Court of Protection twitter feed then sent a public tweet, tagging in His Majesty’s Courts and Tribunal Service (@HMCTSgovuk), asking why the RCJ email addresses for links were not responding and why the phone was going unanswered.  I also understand she emailed people (whose emails are not publicly available) to explain that we were not able to gain access. 

I joined the hearing remotely at 10:30am and the MS Teams Meeting began at 10:50am (twenty minutes later than listed). 

At the beginning of the hearing the judge apologised for the late start, which was due to “technical difficulties” with a previous hearing. She acknowledged that there had been some “difficulties” in public access to the hearing – but on checking who had joined the platform she noted that those difficulties “have been overcome in part by the delay in starting this hearing”.  

Transparency Order

I was not sent the Transparency Order, In court, however, the judge stated (only) that the name or identity of P whether directly or indirectly was not to be published and that the Transparency Order could be requested from the court, which I intended to do. However, Celia Kitzinger sent me the Transparency Order (TO), on the 7thJuly 2023, telling me that she had made an application for it to be varied so as to permit naming the local authority (Kent County Council) – and this variation was approved by order of Poole J on 11th July 2023.  Neither Celia nor I had been made aware during the hearing that the original TO  protected the identity of Kent County Council. This highlights the importance of requesting the TO as soon as possible, either before, during or immediately after the hearing and before communicating anything about the case to others. (Celia has blogged about the issue of the transparency order here: “Varying reporting restrictions to name Kent County Council in ‘shocking’ delay case“.)

The hearing 

As set out in Transparency Order, the barristers in court were: 

  • Bridget Dolan KC for the applicant, Mr N, via his litigation friend the Official Solicitor 
  • Michael Paget for the first respondent, the local authority, Kent County Council  
  • Steven Broach for the second respondent, NHS Kent and Medway Integrated Care Board 

Mr N himself appeared remotely and was accompanied by someone in the care home. The Official Solicitor asked the judge for permission to allow Mr N to turn his camera off, which he did immediately after being granted permission.

After the usual preamble (about not recording the hearing), the hearing was called on by a member of the court staff, and the judge then asked counsel for the applicant for an introductory summary of the case, as recommended by the former Vice President, Mr Justice Hayden (here).  

Bridget Dolan KC introduced all the people in the virtual courtroom and explained that this is a challenge by Mr N to the local authority’s deprivation of his liberty, on the grounds that it does not meet the qualifying requirements of s.21A(2) of the Mental Capacity Act 2005.   

There are six qualifying requirements before someone can be lawfully subject to a Standard Authorisation depriving them of their liberty in a hospital or a care home.

  1. The Age Requirement: that the relevant person is 18 or above 
  2. The Mental Health Requirement: that the person must be diagnosed with a ‘mental disorder’ within the meaning set out within the Mental Health Act 1983, as amended by the Mental Health Act 2007
  3. The Mental Capacity Requirement: whether the person lacks capacity to decide for themselves whether or not they should be accommodated in the care home or hospital in question for the purpose of being given the care or treatment specified 
  4. The Best Interests Requirement (includes 4 conditions): 
    1.  that the person is or will be detained in the care home;
    1.  it is in their best interests to be detained in the hospital or care home;
    1. that this detention is necessary to prevent harm to them; and
    1. that this detention is proportionate to the likelihood of serious harm.
  5. The eligibility requirement: where none of the circumstances apply where it would not be lawful to authorise a deprivation of liberty, as set out in schedule 1A of the Mental Capacity Act 2005. Therefore, relating to cases where the Mental Health Act 1983 applies instead
  6. The ‘no refusal’ requirement – requires there to be no Lasting Power of Attorney, Deputyship, or valid and applicable Advance Decision to Refuse Treatment 

There are two qualifying requirements which Mr N is basing his challenge on.  First, he states that he does have capacity to make his own decisions about residence and care, and therefore cannot be subject to a deprivation of liberty under the Mental Capacity Act 2005. Alternatively, if the judge finds against him on the capacity argument, he argues that it is not in his best interest to be in this particular care home, as it is not near his family. 

There was no mention during the course of the hearing about his “impairment of or … disturbance in the functioning of, the mind or brain” (s.2(1) Mental Capacity Act 2005), but I learnt from Celia Kitzinger afterwards, who had been sent the Position Statement from the Official Solicitor, that he has a diagnosis of treatment-resistant schizoaffective disorder and is living in a care home following discharge from hospital – where he is reported to have been an inpatient since February 2012. 

The case was before a Tier 3 judge in the RCJ for two reasons:

  1.  A s.49 report on Mr N’s capacity had concluded that he does have capacity to conduct this litigation and does have capacity to make decisions about residence – but that he does not have capacity to make decisions about the care he should receive. 
  2. Until the day of this hearing, the local authority had taken the position that the Court of Protection doesn’t have jurisdiction to hear this particular s.21A challenge because “section 21A cannot be used to discharge a DOL authorisation for a restricted patient”.  The local authority said that this application should have been made instead to a Mental Health Tribunal.   

The Official Solicitor’s Position

The Official Solicitor’s (OS) position was that “KCC [Kent County Council’s] position on jurisdiction is quite simply untenable, with no basis in law.  If [Mr N] is found by this court to have the requisite mental capacity that would make him ineligible to be deprived of his liberty under Schedule A1 then, clearly, the standard authorisation of his deprivation of liberty must be discharged.  To suggest as KCC do, that Mr N should be denied the opportunity in the Court of Protection to challenge the qualifying requirements for an authorisation of a deprivation of liberty imposed under the Mental Capacity Act is to trammel his fundamental Art 5 and Art 6 rights.” (From the OS Position Statement). 

By the time of the hearing, however, KCC had withdrawn from that position. 

According to counsel for the OS: “At the pre-hearing Round Table Meeting, we put to KCC that we considered it misplaced. It has now been withdrawn.  KCC accepts that the court does have jurisdiction… The issue of the jurisdiction of the court has now fallen away completely. You can decide whether he has capacity, and whether the placement he is in is in his best interests.  But you can’t order he goes somewhere elseMr Paget will explain the residual issue – that COP has the jurisdiction to hear s21A but cannot demand that Mr N goes to a separate placement.” 

There had also been a further development – a new placement had been found, closer to Mr N’s family, and he wants to go there – on the grounds that if he’s going to be deprived of his liberty, he’d rather be closer to his family.  There are no lesser restrictions at the new placement.  The Secretary of State was content for the move to take place.  All that was holding it up was the funding decision – which is nothing to do (it turned out) with the ICB the court had joined as a party, who would not be the funder.  The only contribution to the hearing made by counsel for the ICB was to say “We don’t commission the services in this case. We have no involvement in this case. We don’t understand why we were joined, frankly.  If there are issues about funding, then it’s NHS England, or the Trust, but it’s certainly not us, and I’m not able to provide any assistance”.  

The judge seemed quite exasperated by this situation. She asked what directions were now being sought.  Counsel for the Official Solicitor said that they wanted an independent expert since the situation of whether or not Mr N has capacity is now complicated and contested. 

Judge:  How long will that take?

OS: We don’t have an expert…. The effect of KCC’s application to dismiss proceedings was that everything was put on hold.  If the court wasn’t going to hear it, there wouldn’t have been a need for a report. 

Judge: I don’t accept that.  It is acknowledged by everyone that you need to do parallel planning so you don’t build in delay.  I would expect to have enquiries made so that somebody was lined up to report so that there would not be delay if what has happened, happened.  All I can do is express my despair.  There’s delay building on delay.  How long do you think it will take. 

OS: We did have an expert who said, yes, he would do it. But now he’s on leave until September.  He had been lined up to do it, but now he’s not available.  Given that August is coming soon, I would not be hopeful for a report before the end of September.  I would like to be optimistic, but we know the reality. 

Judge: Okay, so expert report. What other directions? 

OS: Discharge the ICB. Get the capacity evidence.  Get Mr N’s wishes and feelings regarding the placements. 

There was some discussion about the timetable of events, with the conclusion from the OS being that the case was likely to be ready for a next hearing in September. 

Local Authority 

Counsel for the local authority said there was no dispute about funding and it was anticipated that Mr N could move to the new care home within two months. 

The community team has notified the MoJ and the MoJ has consented to it. And as part of that wants comfort that any similar home would have a similar level of restrictions – namely, amounting to a deprivation of liberty under the Mental Capacity Act.  So, although they can’t impose a deprivation of liberty on a restricted patient, they say they’ll only approve a move where that is so – which amounts to the same thing.  This case was transferred to Tier 3 because of the case law on capacity and secondly to consider what the court can do in relation to s.21A when dealing with a restricted patient.  The court can say whether the capacity and best interests criteria are satisfied, but can’t say the patient should be transferred unless it’s already been agreed by the Secretary of State.  We did say as a bald position in our Position Statement and in correspondence that the court has no jurisdiction.  That is wrong. The court does have jurisdiction.  The court can say whether the capacity and best interests requirements are made out. But what it can’t do is say that a Mr N should be moved from Accommodation A to Accommodation B.” (Counsel for the local authority)

There followed some discussion about the precise remit of the judge and the Secretary of State.  “You can’t require the Secretary of State or anybody to provide a placement they’re not prepared to provide”, said the OS.  “You could say ‘I don’t think the best interests requirement is met because this man doesn’t need 24/7 care – so then the Secretary of State would probably recall him to hospital and then discharge him back to the same care home under s.17, so the conditional discharge would disappear. That would be the practical fix”. 

Counsel for the local authority said, “You can’t give the remedy sought in the s.21A challenge – ‘I don’t like it here and I want to live in [Name of Town] independently’”. 

Counsel for the Official Solicitor looked surprised by this comment.  “That’s just what Mr N’s wishes and feelings are”, she said.  “But our application was not for that.  I’m beginning to understand how this application has gone so horribly awry.  There seems to be a misunderstanding that paragraph 35, which sets out what Mr N’s wishes and feelings are, was somehow an application from us that Mr N should live independently!”. 

The judge said she would keep this case “so I can understand how this delay has come about.  It is not a good reflection on the system that a challenge was made in November 2022, and here we are in July 2023 without a determination and with a three-month delay.  It looks as though it won’t cause too much difficulty on the ground. There is no funding dispute and he can move in early September. He can achieve what he wants to – move closer to his family.  And I’ll have time to read the bundle and understand how this has all come about.”

The judge went through the order, decided on a directions hearing two weeks before the final hearing, and ended by reflecting on the fact that there had been an application, which she’d refused, to vacate this hearing.  “There is a lesson to be learnt about vacating hearings in such a vague and incoherent way.  My instincts were right about not vacating this hearing.” 

Reflections 

I found this hearing an eye-opening experience to the practicalities of Court of Protection cases, including the real-life implications of court delays, the need to provide introductory summaries and the positions regarding jurisdiction. Watching this hearing has strengthened my interest in Court of Protection work. 

Notably, I found it interesting that although the case was brought on behalf of Mr N, the focus was so far removed from him, as the entire hearing was concentrated on the jurisdictional disputes between counsel.  I’m told this was a very unusual hearing! 

Febienne Green is currently working as a paralegal. She completed the Bar Training Course with a masters in 2022. Her masters focused on disability discrimination in medical law, regarding s.1(1)(d) of the Abortion Act 1967 and its effect on persons with disabilities, with a focus on Down’s Syndrome and the case of R (Crowter & Ors) v Secretary of State for Health and Social Care [2021] EWHC 2536. Her ambition is to become a practising barrister. Her LinkedIn page is available here and her email address is febiennea1999@gmail.com.


[1] Quotations purporting to be taken directly from the hearing are based on Celia Kitzinger’s contemporaneous touch-typed notes. They are as accurate as they can be (given that we are not allowed to audio-record hearings) but are unlikely to be 100% verbatim.

Adjournment and interim judgment – Hayden J’s fact-finding hearing

By Celia Kitzinger, 4 August 2023

The plan for the day (Monday 31st July 2023) was to hear the remainder of the father’s evidence, the first part having been heard on the Friday before.  Then the court was supposed to move on to hear evidence from the mother and grandmother of the very vulnerable young woman (G) at the centre of the case. 

But instead, due to sickness of a leading barrister, the hearing has now been adjourned (postponed) for nine weeks, until 6th and 9th October 2023.  

A key reason for the nine-week delay is that Monday 31st July 2023 was the last day of the court year (which is organised into three terms – like the school or university year).  The new court year starts on Monday 2ndOctober 2023.  

The court has already heard the evidence from the witnesses put forward by the ICB (Integrated Care Board). Many care home staff gave evidence over seven days of the previous two weeks, expressing concerns about the behaviour of the family. The carers say the parents have been intimidating and rude to staff and that both parents and the grandmother have tampered with G’s medical equipment, including the equipment used to deliver oxygen, suction and feeding, placing her at risk of harm by interfering with her medical care.

We have heard the father deny this absolutely.  He says that staff at the care home have placed his daughter at risk of harm. He says the care home is failing his daughter – they’ve not properly maintained her airway and lungs, her oxygen supply, her tracheostomy, or feeding tubes.  He says they’ve failed to ensure she has adequate equipment which is properly set up, and that they’ve failed to maintain her personal hygiene, have used unsafe secondary ventilator settings, and failed to administer essential medications.  

These are all very serious allegations – both those by the Care Home and ICB against the family, and those by the family against the Care Home.

The outcome of this hearing will be that the judge, Mr Justice Hayden, will decide the facts of the matter – and those “facts”, as determined by the judge in accordance with the civil standard of “balance of probability”, will have a profound impact on future decisions made for G: on where she lives, who cares for her, and the time she spends with the three closest members of her family.  But as of today, those facts are not yet decided – because only some of the evidence has been heard (all the care home evidence, but relatively little from the family). 

The father’s cross-examination should have continued today, to enable the court to establish the reliability or otherwise of his evidence. And we should have heard evidence from both G’s mother and from her paternal grandmother. 

Instead, in the absence of Ms Nageena Khalique KC, lead barrister for the applicant ICB, the court spent the whole day working out first whether or not to adjourn (fairly quickly decided as ‘yes’) and then when the next hearing could be listed, and then what orders the judge should make in G’s best interests to cover the period between now and the resumption of the hearing.  These interim orders turned out to be somewhat contentious and involved the Official Solicitor in obtaining instruction over the lunch break and providing a written submission for the afternoon session. 

The hearing (morning)

By the time that “Court Rise!” sounded out, and the judge joined the video-platform at 10.22am on the morning of the hearing on Monday 31 July 2023, it was obvious there was a problem.  

Ms Nageena Khalique KC, Leading Counsel for the applicant ICB (and the Care Home parent company),  was not in her accustomed place in the front row to the right of our screens, where we’d seen her for the last eight days of this hearing.  Instead, a much younger barrister, Olivia Kirkbride,  took her place. 

It turned out that Nageena Khalique is ill – she’s had three positive COVID-19 tests – and unable to come to court (even remotely) today.

As in any other occupation, there are different “grades” or “ranks” of barrister, and Nageena Khalique is one of the most senior. She was “called to the bar” – that means, she passed the vocational stage of training and qualified as a barrister – nearly thirty years ago, in 1994, so she’s very experienced.  I often see her in Court of Protection hearings.  She was recognised for her excellence in advocacy by being made a “silk” or “KC” in 2015.[1]   

The barristers acting for the parents are also very well-known and experienced silks: Parishil Patel KC (called 1996, silk 2018) for the father; and Joseph O’Brien KC (called 1989, silk 2022) for the mother.  So, too, is the barrister acting for the protected party (G) via her litigation friend the Official Solicitor, Sophia Roper KC (called 1990, silk 2022).    

By comparison with these other barristers, all of whom are silks, and all of whom have been practising barristers for more than a quarter of a century,  Olivia Kirkbride was “called” (i.e. qualified) in 2018, just five years ago.  She has been in court throughout the hearing as “junior counsel” to provide support for Nageena Khalique as “Leading Counsel”.  But now that her Leading Counsel was ill, it was quickly decided that the ICB/Care Home company would be placed at “a significant disadvantage” if the case were to proceed on that basis at this crucial stage of the hearing.  This was accepted by all the parties, and by the judge (“I don’t think it would be fair to ask you to take up the brief at this stage”).

The problem then was how best to protect G and safeguard her best interests until the hearing could be finished – in the context of what the judge had already described as “little short of outright war” between the care home staff and the family.  

On behalf of G, the Official Solicitor described this as “a significant source of anxiety … and almost despair: it’s a very troubling situation”.  

Interim Orders 

The judge raised the possibility of an order prohibiting all contact between G and her father, mother, and grandmother during the interim period before the next hearing.  I was surprised by this.  If, eventually, the facts are found to be that the care home is right and the family is putting G’s life at risk by tampering with equipment, then that decision would obviously protect G in the interim.  But if, eventually, the facts are found to be that the family is right, and the care home is putting G’s life at risk through negligence or incompetence (and trying to scapegoat the family when errors occur), then that decision puts G at risk by denying her the protection afforded her by her family members, who – everyone accepts – are  very knowledgeable and skilled in caring for her. 

The audio was not good in the morning, but this is what I think I heard the judge and Official Solicitor (OS) say, as they reflected on how best to ensure G’s best interests, over the course of a nine-week break in the fact-finding hearing. 

Judge: It’s about G’s welfare.  I’m the judge responsible for that.  What are the reasonable steps to take now?   It’s difficult to answer that question when there is a fundamental dispute. Can I be satisfied that any contact at all [between G and her mother, father and grandmother] is safe? Would it be reasonable to allow unsupervised contact at this stage? What are the safeguarding obligations? And factored into that, the important evidence that G is, as I’ve hinted at a number of times, at the end stage of her life, however long that may be: that, I think, has to be factored into a person-focused, G-focused, arrangement that somehow balances both the identified risks and the welfare benefits. That’s what I have been struggling with. I’m not finding that easy.

OS: My Lord,  it’s not easy for anyone. I’m aware of the points Your Lordship has made. I also have in mind the points all the other parties have raised that their evidence has not yet been adjudicated on. The outcome if either set of allegations is found is potentially very profound for G.  It is not being suggested by anyone, including the Official Solicitor, that it is not safe for her to have unmonitored contact with her parents. 

Judge:  I am saying it.

OS: I recognise the court is entitled to make that suggestion, even if no party is advancing it. But the Official Solicitor is not advancing the position that G is at risk in the care of her parents or grandmother. The allegation from the ICB and [Care Home parent company] is that they say the reason why the family are tampering with equipment is to make the nursing home look incompetent. Yhe Official Solicitor  is not making a submission as to whether that case was made out, but that is the most logical explanation.

Judge: It is not logical to make a submission that the loving parents will interfere with equipment and threaten the welfare of their child for that reason  – but, if it is right,  is it safe to assume the parents would confine that interference to in the care home and not outside the care home?  It’s a risk dependent on location?

OS: Yes.

Judge: I have not come to any view at all.  I have been grappling with this […]  But confronted with this significant adjournment, the period of the next eight weeks is a particularly tense one for the family and for [the Care Home].  (inaudible) … serious allegations and counter allegations.  The whole scenario is ripe for difficulties and there have been difficulties historically for years. These are very, very, very difficult issues to balance. 

The judge sat silently for a while, apparently sunk in thought, hands clasped, the finger of one hand drumming against the knuckle of the other. He then raised another issue:

Judge: Has any thought been given as to whether [the Care Home] staff could be taken out of the picture altogether?

OS:  I don’t have specific instructions as to whether it would be said by the Official Solicitor  that there’s a prima facie case on the allegations so as not to (inaudible) I  don’t think the Official Solicitor would say that the risk on the evidence so far would support cessation of contact altogether, or only supervised contact.

Judge: I am not necessarily with you on that.

OS: I appreciate that and will take instructions. 

The sound then kept cutting out and everyone sounded intermittently as though they were under water.  I did hear the  judge say “I‘m going to have to have some analysis in writing about this” and make a reference to “tampering with life-sustaining treatment”.

Counsel for G’s father (Parishil Patel [PP])  got to his feet.  The sound quality was really poor by now and kept cutting out.  This is what I got down: 

PP:  I do want to say this one thing, My Lord.  Your Lordship  indicates what you’ve been thinking. There is detailed evidence about the standard of the care from both [G’s parents]  and corroborated by the evidence of the care notes…[???] That is a matter Your Lordship  hasn’t had a chance to [????]  On the one hand, the family are saying not only do we not tamper with the equipment, but the care home is unsafe, and you haven’t made a finding.  And they do say that, actually,  that this is an unsafe place for G to be.  If one is then going to come to a view about what is best for G before you’ve made any findings, then you need to bear in mind what family say [???? ]. We haven’t heard the evidence about what has been happening [????]. Hold the ring [????] ….  In order to disturb what was Your Lordship’s view back in February,  you would need a change in circumstances, particularly if you are going to change contact arrangements.

Judge: I understand all those points. [????] safeguarding [????] That creates a very clear tension.

By 12.34pm, the sound had gone completely.  I watched Parishil Patel speaking, apparently forcefully,  at one point beating the air with his hand.  But I heard nothing of what he said.  Both he and the judge looked somewhat tense. Shortly afterwards, the hearing ended for an extended lunch hour, during which I understood Sophia Roper was to seek instruction from the Official Solicitor as to what her proposals were as to what order could best promote G’s best interests during the following nine weeks.  

Meanwhile I emailed the judge’s clerk letting her know that the sound quality had now deteriorated badly, in the hope that she might be able to fix it during the lunch hour.  She did – and the sound quality was excellent in the afternoon.

The hearing (afternoon)

Each of the parties, except the grandmother (who is a litigant in person) got a ‘slot’ to present their position on the interim order. (I don’t know if the grandmother declined her slot, or if she was forgotten – as has sometimes been the case at various points in the hearing).

The ICB and Care Home

When the hearing resumed at 14:37, Olivia Kirkbride (for the ICB and the Care Home parent company) addressed the judge with some of the questions he’d raised beforehand (not all of which I’d heard).  She said that that the Care Home wanted to maintain the placement for G, with safeguards in place to help them to deal with the situation.  She said that staff had found giving evidence highly stressful and that there was a high degree of anxiety about having interactions with the family at the present time. But she did not propose further restrictions on family visits. 

There had been internal discussions about handover (i.e. when the parents arrive at the care home to collect G to take her out into the community, and when they return her in the evening) –  and they proposed that a designated member of staff from another unit, or even someone independent of the care home altogether, should be responsible for this.  I think the judge had asked for a list of how many times the family had returned late for handover, in breach of the injunction, but this seems not to have been provided.  

Counsel also reported that staff were stressed by the number of phone calls they were receiving from the family – including one apparently during the lunch break that very day from G’s father asking about her wellbeing.  (I noticed he was shaking his head as if to indicate that this was not the case: he wrote something down, and passed the note forward to his legal team.) 

Official Solicitor

The Official Solicitor had sent the judge a written submission, which (very helpfully) was also shared with me. As it turned out, the judge relied heavily on that submission in delivering his judgment (see below). 

The Official Solicitor also did not propose restrictions on family visits beyond those already in place from the last hearing.  The previous order from March sets out three visits a week, at prescribed times. When the family arrive at the care home there is a designated place for them to wait for G to be brought to them (“the Quiet Lounge”, just inside the front door).  Using a member of staff from a different unit takes the pressure off staff and “may assist family as well because they are not dealing with anyone who is responsible for anything they’re unhappy about”.  There seemed to be “some support” in the care home records for there be an excessive number of phone calls, which add to staff stress.

Counsel for G’s father

Counsel for G’s father, Parishil Patel, has been a consistently impressive advocate in this case, with a comprehensive grasp of the complex and exhaustive evidence before the court. He’s shown a gift for navigating the bundle and presenting the voluminous material before the court in straightforward terms.  He’s also been persistent and meticulous in his cross-examination of witnesses and forthright in his defence of his client (intervening several times with “objection!” into other parties’ line of questioning). The judge recognised this at the very end of the hearing when he said “I do not believe anybody could have put their case with greater thoroughness and industry than you have on [G’s father’s] behalf”.   This advocacy has sometimes involved, if not outright altercation,  at least (what look to me like) tense interactions with the judge.  

Picking up on the judicial concern with conflict between family and care home staff, Parishil Patel said,  “it isn’t accepted that there is conflict at handovers” and pointed (again) to the fact that the family haven’t yet given evidence.  There was then an exchange between Parishil Patel and the judge which seemed to hinge around a difference in nomenclature as to what does and doesn’t constitute “handover” – with the judge pointing to an occasion on which it is alleged that G’s mother “barged into the care home with the wheelchair” when returning G to the care home several hours late (due to transport problems): according to the night nurse, she was aggressive and shouting, and damaged the nurse’s foot with the wheelchair.  (This was part of the evidence given the previous week.)  The judge seemed to be taking “handover” to mean any occasion on which G was passed from the care of her family to the care home staff, or vice versa.  Counsel seemed to be taking “handover” to mean the process that had been devised for checking the equipment in the course of that process.  The exchange became somewhat testy.

Judge:  Mr Patel, no doubt it’s my fault but I don’t think you’re following my concerns. The heat of litigation has been increased, not diminished, by the litigation of the last few weeks. I want to anticipate the sources of conflict rather than looking back – and make sure there is no room for ambiguity. I have no difficulty understanding why people come back late if they’re relying on public transport.

PP: That was the reason in every case.

Judge: I don’t need to rehearse the litigation.

PP: I know, but I‘m telling you.

 The judge checked what arrangements the care home thought were (or should be) in place when the family returned late, and also asked about flexibility relating to visits on days other than the designated days when G was unwell, and visits from other family members (e.g. G’s sister). 

Parishil Patel then spoke of the “absolute joy and love that there is between G and her family and the pleasure that she receives out of contact with her family”, which had already been conveyed by the father in his witness evidence. It seemed uncontested that the family have ways of communicating with G – and she with them – that are not available to the staff.   He pointed out that if the judge were to think that G’s best interests were served by a reduction in her contact with her family, “that would mean she’d be left in company of staff, and you’ve heard that they don’t have or haven’t developed the level of interaction that her family have with her, so that would be a major disadvantage to G in that balancing exercise”.

Counsel for G’s mother

Counsel for G’s mother, Joseph O’Brien, said he wanted to “adopt and endorse everything Mr Patel has said in this case”.  He pointed out “You’ve yet to hear from my client”.  He raised the concern that there might be a risk that what had been said in court might “leave my client with the impression you’ve already formed an opinion”.  Given that the other parties all thought contact between G and her family should continue over the course of the next nine weeks, he said that G’s mother “will be extremely grateful and her confidence restored” if this were to be the judge’s decision also. 

And then the judge gave an ‘ex tempore’ judgment.

An interim ‘ex tempore’ judgment

An ‘ex tempore’ judgment is an oral judgment handed down orally during a hearing  – often without a break in the hearing, or sometimes after a short break (15 minutes to an hour in my experience) to allow the judge to gather their thoughts. The term ‘ex tempore’ is Latin for “out of the moment”.  The other way a judge delivers a judgment is to “reserve” it – meaning they hand it down in writing later  – usually days,  weeks or even months after the hearing.

On this occasion, Mr Justice Hayden’s ex tempore judgment was delivered without a break in the proceedings.  He asked the junior counsel to take a note of the judgment and to send him an agreed transcript of it, which he will then have the opportunity to “perfect”.  

“Perfecting” a judgment begins with filling in any missing words or phrases that counsel were unable to hear, and correcting any mistakes counsel may have made in rendering the judge’s words in print. It includes dealing with any problems in grammar and punctuation, and any lack of clarity in the way the judge has expressed their reasoning.  The parties also have a duty to correct any errors the judge has made – although this is not an opportunity to reargue the case or try to persuade the judge to change their mind. The judge can make these corrections, alter the wording of the judgment, and add in new sentences with additional reasoning explaining the decision reached.  The judge has discretion to change – even reverse –  their decision at any time before their order is sealed by the court (although this is very rare)[2].  

So, what follows is a long way from having the status of an ‘approved judgment’ in the same sense that the published judgments on BAILLI and the National Archives do, but it is (to the best of my ability) an accurate record of what Hayden J said In judgment in court.  As barrister and blogger Lucy Reed says: “Use of the phrase ‘transcript of judgment’ to describe an approved judgment probably isn’t helpful because it doesn’t make clear this distinction between a transcript (the raw material) and the judgment (the finished product)’.[3]  What I’ve captured below is the raw material. I don’t know if there will be an approved published judgment – and I haven’t seen the order.

Mr Justice Hayden’s ex tempore judgment

“Allegations brought by the ICB, the applicants in this case, and the countervailing allegations brought by the family, have properly in my judgment been described as being of the utmost gravity and which if found, in either case, have far-reaching implications for G’s welfare. G is the 28-year-old young woman at the heart of these proceedings, whose welfare responsibility this court is charged with. Because of the nature of the allegations, the Court of Protection took what is the very rare – and I hope will continue to be very rare –  (though not unprecedented) measure of convening a fact-finding hearing. As it transpired, the time estimates of the hearing had not proved to be accurate. I state that as fact and it is not to be taken by anyone as a criticism.  Only by sitting long and quite demanding days has it been possible to keep the case, broadly speaking, on track. 

Unfortunately, counsel has been taken sick with covid over the weekend and is not in a position to proceed. That is a reminder that we are still living with this insidious virus.  Given we’ve reached a point where family were in process of giving evidence, I have taken the view that it would be unfair to burden Ms Kirkbride, junior counsel for the ICB, with the responsibility for taking up the reins of cross-examination at this stage. Inevitably, therefore, the case has had to be adjourned. In the finest tradition of the Court of Protection Bar, both 

Mr O’Brien KC and Mr Patel KC  have agreed that such a course is necessary.

On the very last day of the Trinity term, this presents considerable problems. Though I should have preferred that the conclusion of the case be heard in my vacation slot at the end of August,  I recognise that the logistics of that are not in our favour, so I have concluded that the case should recontinue at the earliest possible date at the commencement of the new term, and it’s been possible to fix the case for 6th and 9th October. 

Axiomatically, that poses a real challenge for interim arrangements for G’s contact with her family.  There are, as I see it, two central issues here. The family assert that G is essentially at risk in the care of [the Care Home], whose standard of care for her they contend falls below that which her welfare needs necessitate and which she is entitled to expect. Explicitly, they contend that she is unsafe.  And it is not appropriate at this stage to burden this short extempore judgment with the more graphic adjectives which have been employed [????][4].  

The ICB countervailingly  assert that the family, led by the father, have mounted an insidious  campaign to destabilise the placement and to undermine the staff – which it is contended involves essentially abusive behaviour to staff, and a level of interference with G’s care that jeopardises her welfare and safety.

The level of conflict at this hearing has been almost palpably tense and distressing to watch, not least for the nursing and care staff. The presentation of each of the witnesses from [the Care Home], whatever its genesis, has been profoundly troubling.  

Irrespective of what my ultimate conclusions might be on the evidence – evidence which I emphasise remains incomplete – I have formed the view that the placement at [the Care Home] for whatever reason is manifestly hanging by a thread. Nobody sitting in this court for the last few weeks or watching it remotely, could come to any other conclusion. 

It is contracted as an intensive placement for a young woman with complex needs. If it is not already obvious from the evidence that the court has heard [????], it would be immensely difficult to find an alternative establishment – a difficulty which will no doubt have been exacerbated by the history of this case, whatever my ultimate conclusions on the facts might be.

The risks to G’s welfare which have in the past few months under the regime that this court ordered been manageable, have, in my assessment increased – not diminished – by this corrosive, highly litigious, and profoundly troubling period that is inevitably the consequence of litigation of this complexion. In this jurisdiction in particular, which ordinarily focuses on questions of capacity and best interests [????} however sensitive and complex the issues might be, questions of credibility arise only very rarely. The relationship between staff and family was described as being “at rock bottom”.  On that, if on nothing else, I suspect both sides would agree.

An important aspect of the ICB’s case is that family members, most particularly the father and paternal grandmother, have tampered with the machinery upon which G relies to breathe. The motive identified for such otherwise incomprehensible behaviour was it had been done to manufacture evidence of the incompetence of [the Care Home] staff.  Ultimately, I will have to evaluate the cogency of evidence in support of those allegations, but if they are found to be made out, they reveal a disturbing, dangerous, and in my judgment unpredictable mindset.

During the last 2 weeks, in the course of this hearing, the parents have had no contact with G –  and faced with a considerable period of adjournment, it is the responsibility of the court to consider how the risk of contact between G and her family can be managed in the interim, given the increase in temperature of the conflict which these proceedings have, in my judgment, generated. 

Indeed, I have asked myself as I am bound to do considering the nature of the allegations whether it would be right to reintroduce contact at all. Notwithstanding the general consensus that G enjoys time with her parents, and I would add  gains a reassurance from their presence and touch which no one else can deliver, the Official Solicitor believes, and I agree, that at this point, the preservation of the stability of the placement remains the priority – the apex of G’s identifiable needs. 

Unless or until any of the criticisms levelled by the family is established, [????} in the interim, the placement has been observed by independent professionals, e.g. Dr A who is satisfied that G is not [at risk?] in her placement. And I do not need to be reminded that that evidence is, like so much else in this case, challenged. 

I have had to turn to the Official Solicitor to assist in evaluating the way forward in the interim that keeps G’s welfare needs, her best interests, unwaveringly in focus. That is not concerned with ‘holding the ring’, nor should the contact arrangements put in place be driven by the general exigencies of the litigation.  It is always G’s evolving needs that have to be (as I have said) the unflinching focus.  

Ms Roper on my request, along with her junior, Mr Harrison, have been able to put a document together on behalf of the Official Solicitor, G’s litigation friend, mapping out the Official Solicitor’s analysis how the process I have identified can best be [????] over the course of the next two months.

Ms Roper and Mr Harrison emphasise the following.  

Firstly, [the Care Home]  has not alleged that any family member has tampered with G’s equipment while she has been out with them, at any point since she was discharged there on 18 August 2022.

Second, there are no allegations of any tampering with G’s equipment at all since the current contact regime began, following G’s discharge from A Hospital on 7 March.

Third, the checklists completed by both sides on handover since 7 March ensure that there is an effective rigorous process of professional oversight and complete accountability as to the condition of G’s equipment – both when she leaves [the Care Home], and when she returns.

These key facts, it is contended, point to a manageable risk.  

I have had to go further and ask myself whether those protective factors are likely to endure at this particularly tense period in the context of allegations which I have already emphasised [???] reveal an unpredictable mindset. 

To fortify the present arrangements, the Official Solicitor contends that direction can and should be given for weekly disclosure of all the records of [the Care Home] including correspondence, and secondly, some provision made for this case to gain urgent return to court in the event that quote “any tampering is suspected”.  For my part, I would modify that last phrase to state ”reasonably to believe” that tampering has occurred.

That involves one aspect of the court’s concern. The second is the sustainability of the placement which, I repeat, I have characterised as hanging by a thread, with staff morale at rock bottom. Ms Roper addresses that in this way.

Firstly, she points out that of those witnesses who were asked about imposition of a restrictive regime of contact post-7 March 2023, their general response was to the effect that it has proved to be manageable albeit that that has not had much by way of positive impact upon the morale of the staff.

The return of G from contact –  and the potential flashpoint of what I have called ‘handover –  has the Official Solicitor asserts been ameliorated by the present regime, as I understand it, of deploying a member of staff from a different unit within [the Care Home] to facilitate that process.  It is plainly important that that member of staff is provided with a written handover guide setting out any updates for the family and that the checklist is completed with the family in attendance.  

Thirdly, the effect of the current regime is there is no face-to-face contact between the family and those who are immediately responsible for G’s  day-to-day care at [the Care Home]. That involves a number of those nurses and carers who have given evidence before me. That separation between the family and the nurses and carers intimately involved with G’s care on a day-to-day-basis, is manifestly undesirable. It serves if not to block but to my mind inevitably impede a channel of communication which ought to be regarded as intrinsic to her wellbeing. The fact that it is advanced by the Official Solicitor on G’s behalf as an important protective measure to her wellbeing (i.e. that there be no such contact) is an indicator of how far this case has drifted from the ordinary safe moorings of a collaborative relationship between family and carers.

Fourthly, the Official Solicitor has been told – and Ms Roper says this is supported by some of the records – that the outstanding pressure point is the number of calls being received from the family. Mr Patel tells me they are not as numerous as is being presented, or alternatively that they are only made when strictly necessary. Ms Kirkbride sets the scene for the issue by telling me that there was a phone call this morning, notwithstanding the case (???).  The Official Solicitor has concluded that a satisfactory channel of communication could be devised by the allocation of a designated senior member of staff who would call a family member with a general update on a daily basis on those days when the family aren’t visiting. The Official Solicitor recognises that while that may have benefit in reducing the potential for conflict, it cannot be set in stone, because of the nature of G’s condition, and the ever-present potential for her to become unwell. Any such arrangement, it requires to be stated explicitly, should not exclude the professional – and I would add moral – obligation to contact the family as expeditiously as possible if G were to become ill outside of the suggested arrangements.

Mr [Care Home Manager]  indicated during the course of his evidence in the witness box, that he was willing to offer the family greater flexibility of contact, particularly if a day was missed. {The Care Home ]has been able to demonstrate flexibility recently when they were able to negotiate G’s attendance at her grandmother’s marriage to Mr E. In a case without very much sunshine, that was at least a shaft of it – and it encourages me to think potential for flexibility in contact remains if a day is lost. The principle of substituting a day will of course [be dictated by P’s needs?].

There has been some suggestion, which I have not explored, of the possibility of a vehicle being made available to the family to enable them better to withstand the unpredictability of the public transport provision around [the Care Home] and ensure a greater degree of consistency regarding G’s return. Here, too, there is some tentative cause for optimism.  The time of return is now prescribed by injunction, the force of which appears to have been met.

Whilst I have found these interim arrangements to impose some really serious issues at this stage, and whilst I can see that they might very well be replete with potential for conflict, I am satisfied that the protective architecture that the Official Solicitor has suggested is sufficient to enable me to evaluate the risk as a manageable one, given that in taking it, I will be able to maintain G’s contact with her family, which she not only derives pleasure from but which requires to be recognised for what it is – her right, which should only be displaced where there are cogent reasons to do so.  Ultimately, I am satisfied that those reasons do not exist and that basis [????] the proposals advanced by the Official Solicitor.

Parties will know that I have not found this an easy decision. Evaluating the [????] is difficult and many would err on the protectionist side. In recognition of the importance of the relationship between G and her family and the general canvas of her circumstances I believe this is a manageable risk that ought to be taken.

It does follow, however, that if something goes wrong between now and 6 October, that delicately balanced risk might easily be displaced and require revisiting.

I profoundly hope that the contact between now and 6th October will provide me with the opportunity to read something joyous about G’s life.  But far more than that, I hope for her that what will be in effect the remainder of this rather soggy summer will nonetheless be a positive and happy experience for her.

****

Celia Kitzinger is co-director of the Open Justice Court of Protection Project. She has observed more than 460 hearings since May 2020 and written more than 100 blog posts. She is on LinkedIn (here), and tweets @KitzingerCelia


[1] The letters “KC” after a lawyer’s name stand for “Kings Counsel” (previously QC for Queen’s Counsel).  Lawyers who are KCs are often referred to as  “silks”, which comes from the uniform upgrade they get – from the plain black gown most barristers wear in court to a shiny silk one (hence “taking silk” as a description for this promotion).  The emergence of the Queen’s Counsel during the late 16th and early 17th century was during a time when silk was a rare and expensive commodity. Later, King James I was particularly fond of it and keen to exploit its production throughout the colonies. The king’s preferred barristers would be dressed in his favoured fabric. Check out “What is a silk” and “Taking silk” – according to the which, “adding those precious two initials [KC] to your title gives you status and privilege that most in the legal profession will only dream of”. 

[2] See: §16-§46 In the Matter of L and B (Children) [2013] UKSC 8  for some legal history concerning altering judgments (thank you to Daniel Cloake aka @MouseInTheCourt for bringing this to my attention). See also: Altering draft judgments; “When a judge changes their mind”; and the very useful blog post about what’s in a recording, what’s in a transcript, and what’s in a judgment and why, by Lucy Reed in Pink Tape here: “What’s in a judgment anyway?”

[3] I’m grateful to Claire Martin who was also in this hearing and made a detailed note of this judgment. I checked my transcript against hers, which enabled me to add in a few missing words, and to gain confidence that what I had written down was largely correct.  Missing words in my version were also very frequently missing words in her version though.  Hayden J can be hard to hear in court (both in person and remotely). 

[4] [????] indicates places where the word (or words) spoken were inaudible, both to Claire and to me. 

Coma and treatment withdrawal: An unusual case

By Rhiannon Snaith, 2nd August 2023

Note: The judgment has been published here: Re IN (Withdrawal of CANH) [2023] EWCOP 32

This case (COP 14094683, before Mr Justice Poole) was heard in the Royal Courts of Justice on Friday 21 July 2023. The hearing was listed as a ‘hybrid’ hearing which meant that people could attend either in-person in the courtroom in London, or via a video or telephone link. In my case, I attended remotely using Cloud Video Platform (CVP).

I received both the link and, a bit later, the Transparency Order on the morning of the hearing which was scheduled to begin at 11am. The person at the centre of the case (IN) is a 55-year-old man who is currently in a coma after suffering a severe pontine haemorrhagic stroke whilst driving his car, resulting in a car crash. Consequently, IN suffered both a cardiac arrest and hypoxic brain injury. He has been in a coma for over 6 months and is currently being treated in a neuro-rehab ward in Hospital. 

It was indisputable in this case that IN lacks capacity to make his own medical decisions.  The question before the judge was to determine whether treatment, primarily CANH (clinically assisted nutrition and hydration), should be withdrawn or continued. 

As is common in hearings such as this, a focal point throughout was what IN would want for himself in this situation. As stated by Mr Justice Poole during the hearing, IN “has not made an advance decision and has not appointed an attorney” – so there was no record of what treatments he wanted to refuse under what conditions, and he had not appointed anyone to make decisions on his behalf if he became unable to do so. 

Furthermore, it became clear that IN and his family had not previously discussed his wishes which meant that determining what IN would want for himself in this situation was incredibly difficult. The family believe that he would want to continue treatments, with his daughter saying that she would want him to “pass away naturally”. But the judge said towards the end of the hearing, “in terms of beliefs and values there is no clear evidence that the court can use as a marker to determine one way or the other what he would want in this circumstance”.

The hearing 

The applicant in this hearing was the Trust, represented by Rhys Hadden. The application was made to the court to ascertain whether it is lawful and in the best interests of IN to discontinue CANH. Two members of IN’s family – his brother and his daughter – were parties to this case as litigants in person, (i.e., they did not have legal representation). 

I noticed that, Emma Sutton KC, who was present as counsel for IN via the Official Solicitor asked questions throughout the hearing in order to assist the family’s understanding. 

Also present at the hearing was IN’s treating doctor, Dr N, and independent expert Dr Andrew Hanrahan

As the hearing began, the judge first spoke to IN’s family. He asked how they would prefer he refer to IN, to which the family responded that they did not mind. He also explained that they were able to give evidence if they wished and checked whether an interpreter was needed for IN’s daughter who joined remotely. She indicated that she did not need one but said “I don’t know because I have emotions, maybe I will”. The judge also explained that there were observers present who would be able to report, or comment, on this case but were not permitted to publish anything that would identify, or be likely to identify, either IN or any of the family members. 

Counsel for the Trust 

Rhys Hadden, counsel for the Trust, provided a useful summary of the case for those attending the hearing. He explained that IN, who also has Type 2 diabetes and is receiving insulin, is currently in a coma and is being treated in a neuro rehab unit in a hospital, to which he was admitted in December 2022. It was explained that following his accident, IN’s brain has atrophied globally, and he has been consistently assessed as being in a low awareness state below the vegetative state (VS). Mr Hadden explained that the Trust’s view is that IN’s coma is “irreversible” with no prospect of recovery and any further treatments would be “futile”. It’s said that the burdens of treatment far outweigh their benefits. As a result, it is the Trust’s belief that it would be in IN’s best interests for CANH to be withdrawn with IN being subsequently “placed on a palliative care pathway”.

The application made by the Trust was, primarily, to address the following issues: 

  1. Whether IN lacked the capacity to make his own decisions regarding his medical care and treatment. 
  2. What would be in IN’s best interests with regard to medical treatments. 

In order to have capacity to make a decision, a person needs to be able to understand, retain, and weigh information relevant to the decision they need to make (s. 3.1 Mental Capacity Act 2005) and then communicate their decision. It was uncontroversial that IN did not have the mental capacity to make a decision in this case. 

Judicial visit 

The judge told the court that he had, accompanied by a representative of the Official Solicitor, recently visited the patient in hospital stating: “I introduced myself to him… an occupational therapist stood by his bed with me and answered some questions about his care”. The judge noted that IN’s bed area “had no personal touches except for poster that I would describe as iconography” that was placed above his bed. It was later established through a discussion with IN’s brother that the poster had been brought by a priest who had visited IN, who belongs to the Romanian Orthodox church.

Witness evidence 

Next, IN’s treating doctor, Dr A, a consultant in rehabilitation medicine, was called to provide evidence. During this section of the hearing there were some audio issues with Dr A’s audio being distorted and indiscernible. It was suggested he disconnect and reconnect again, and to also find a headset if available to help mitigate these issues. After a few minutes, Dr A had logged back in and was using a headset, after which the issue with the audio was not solved but seemed slightly better (at least to me). 

Dr A stated that he had been treating IN since March 2023, though he had previously visited him in the intensive care unit. Dr A stated that though “there isn’t a category of persistent coma state or chronic coma” if there were, that is the category that IN would be in. He said that IN has no awareness and no sleep/wake cycle, further stating that IN is in a persistent vegetative state (PVS). Dr A explained that though he has treated many patients in PVS, he has “never have I seen a patient with no sleep/wake cycle seven months down the line”. Ordinarily, it is rare for a coma to last beyond two to four weeks. 

When asked about the prospect for someone in IN’s condition to progress from a coma state to a vegetative state, Dr A stated that due to the duration of time that IN has been in a coma, paired with the fact that there has been “no positive trajectory”, this prospect is non-existent. In terms of his quality of life, Dr N stated that IN “has very poor quality of life”: he is fully dependent on nursing staff for all his care and day-to-day needs.

If it was ruled that life sustaining treatment should be withdrawn, Dr A explained that they would “remove nutrition and hydration, and insulin but keep tracheostomy and administer medications via a PICC line to keep him comfortable”, though he stated that he cannot be “100% sure” that IN would not experience any pain. Dr A said that he had a discussion with Dr Hanrahan about his experience in similar cases, and that Dr Hanrahan’s opinion was that if they were to take away the tracheostomy IN would struggle to breathe which would be distressing for both the family and the care staff. “So, I think on reflection I have suggested that we do not remove the tracheostomy”.  If CANH were not to be withdrawn, Dr A stated that they would “put in a feeding tube [directly into his stomach] and would seek to place [IN] in a nursing home” that would be able to care for his needs. Currently, IN has a nasal-gastric tube for feeding.  

Regarding the issue of pain, Dr A described the two measurements that have been “intermittently used to assess his [IN’s] pain”. He said that both scales have been used on more than one occasion and that IN has rated significantly low on both scales. Dr A further stated that the only response they have seen that may indicate that IN is in pain is a grimace. When questioned further on this, Dr A said, “When you move his legs or sometimes when we take blood samples and when he is moved, there is a small twitching of his face which we surmise to be a grimace… And other times we take a blood sample, and he wouldn’t bat an eyelid. There’s no consistency about this.” 

The judge asked Mr A “In terms of the step-by-step withdrawal, what if there was an apparent change in his level of consciousness during the stages that are set out in this plan, what would happen then?” To which Dr A responded that if there was a “surprising” improvement that they would withdraw from the plan and seek further advice. The judge then went on to ask, “If palliative care is given what would that involve?” Dr A explained the plan would include pain and secretion management, medication to help with breathing struggles, and the use of midazolam to control any seizures IN may have – all to help make him as comfortable as possible. 

When IN’s daughter was asked if she would like to ask Dr A any questions, she raised the concern that her father would feel thirsty or hungry if CANH were withdrawn. This is often a concern for family members and loved ones of the patient. Dr A explained that while he can’t be sure IN wouldn’t feel pain or discomfort, they would use drugs that suppress the central nervous system, and the expectation is that IN would be in “such a deep sleep” that he would not be able to feel anything. 

Following this, IN’s brother was also invited to ask any questions. It was at this point that IN’s brother questioned why Dr A wanted to “disconnect” his brother from treatment from the moment that IN was moved to the neuro rehab ward. The judge then clarified and asked Dr A “did you at a very early stage take the view that nutrition and hydration should be withdrawn?”. Dr A replied that no, he did not. He stated that he wanted to seek evidence of IN’s level of awareness which they did and that once they were certain that there was no positive trajectory, they contacted the court. 

Dr A stated that he wished to clarify that “My personal beliefs are extremely pro-life, and we have a lot of patients in PDOC [Prolonged Disorders of Consciousness] at [Hospital]. I frequently see such patients and I have never once approached the court for withdrawal of CANH because that is not something I take lightly. This is something I find quite distressing and difficult to handle.” He continued: “If I found the patient to be in a vegetative state, I would have no problems putting in a feeding tube and transferring him into the community, to a care home. That is the easy option. Taking the case to court is the harder option, but I strongly believe that is the right answer in this case.”

Expert Witness: Dr Andrew Hanrahan, Consultant in Neuro-Rehabilitation

Dr Hanrahan reiterated Dr A’s observation that this is “an unusual case” as it is rare to have someone in a coma (as opposed to VS) for over 6 months. He agreed with Dr A that IN’s life expectancy, if all treatment were to be continued, would only be a few more months. This is because IN has many risk factors including diabetes, stroke, infections, and prolonged immobility which may impact his life expectancy even if treatments were continued. 

When asked about the detriment of keeping IN alive for the 3–6-month period should treatment be continued, Dr Hanrahan argued that “discontinuing is not the point. The point is about whether you can continue it without consent”. 

This presents the very important point that if someone cannot give consent to the treatments being provided, then they can only be provided under specific circumstances.  This is how Baroness Hale put it in Aintree (Aintree University Hospitals NHS Foundation Trust v James [2013] UKSC 67; [2014] AC 591)

“19. … Generally, it is the patient’s consent which makes invasive medical treatment lawful. It is not lawful to treat a patient who has capacity and refuses that treatment. Nor is it lawful to treat a patient who lacks capacity if he has made a valid and applicable advance decision to refuse it: see the 2005 Act, sections 24 to 26. Nor is it lawful to treat such a patient if he has granted a lasting power of attorney (under section 10) or the court has appointed a deputy (under section 16) with the power to give or withhold consent to that treatment and that consent is withheld; but an attorney only has power to give or withhold consent to the carrying out or continuation of life- sustaining treatment if the instrument expressly so provides (section 11(8)) and a deputy cannot refuse consent to such treatment: section 20(5). 

20. Those cases aside, it was recognised by the House of Lords in In re F (Mental Patient: Sterilisation) [1990] 2 AC 1 that where a patient is unable to consent to treatment it is lawful to give her treatment which is necessary in her best interests. Section 5 of the Mental Capacity Act 2005 now provides a general defence for acts done in connection with the care or treatment of a person, provided that the actor has first taken reasonable steps to establish whether the person concerned lacks capacity in relation to the matter in question and reasonably believes both that the person lacks capacity and that it will be in his best interests for the act to be done. However, section 5 does not expressly refer both to acts and to omissions, the giving or withholding of treatment. The reason for this, in my view, is that the fundamental question is whether it is lawful to give the treatment, not whether it is lawful to withhold it.”

The family said they wanted “a ‘natural death’ for IN.  This is a view often expressed in cases such as this. However, it can also be argued that discontinuing treatments could allow a natural death, as it removes artificial interventions that delay the dying process. Dr Hanrahan argued that it is “equally natural not to eat and drink after a severe brain injury. It is also a way of allowing natural death”. Furthermore, Dr Hanrahan stated “it is clear to me that IN is, in clinical terms, dying” with it just being a question of trajectory, time and interventions that interrupt the natural process of death.

When referring to the grimace that was mentioned by Dr A, Dr Hanrahan said it is “a neurological phenomenon not an emotion”, as he argued that when there is little neuro-connectivity, the face is where you are most likely to see motor movement. He said that when the nervous system is badly damaged, the most common response to any stimuli (even pleasant ones) is a grimace. Dr Hanrahan’s statements further support Dr A’s assertion that the grimace does not necessarily mean that IN is experiencing any pain or distress. 

In terms of the palliative care plan, Dr Hanrahan suggested that it would be more benevolent to keep the tracheostomy in place, but to deflate the cuff as it “reduces risk” by creating an “alternative airway”. He stated that with regular mouth care, secretions can be managed which would reduce the worry of secretions appearing and moving elsewhere. Additionally, it was Dr Hanrahan’s belief that nothing could be added to the palliative care plan and that the plan would prevent IN from suffering. He stressed that “the event of dying, it should be as comfortable, and peaceful as possible”. 

Family beliefs

When IN’s brother came forward to provide evidence (via an interpreter), he spoke fondly of his older brother describing him as “an openhearted man with a lot of strength”. When describing IN, his brother spoke of the importance of religion to IN, “he was a believer in god” who attended church every Sunday even after he had moved to the UK

When giving evidence, he asked that if his brother has months left to live then “why can’t they let him pass away on his own?” The judge responded by stating that evidence was that IN had between 3-6 months to live if CANH was continued and asked IN’s brother whether, in his view, it would be in IN’s best interests to continue CANH. He responded, “I am not God to make a decision”. Though he later said, “I think he [IN] would like to see if he would be able to get better because he is a man who has been through lots”.

When asked about his brother’s health before his stroke, the brother explained that a year before, IN had to undergo heart bypass surgery, and after 2-3 months of recovery he returned to work. He points to this instance as testament to his brother’s strength. 

In his final comments to the judge, IN’s brother says, “The only thing I can say now is why should we take his life so early before his time is due and why should we not allow him to pass away the way it is supposed to be, the way God would say [want].” 

IN’s daughter took a similar stance stating that she would prefer her father to continue with the current treatment. As per her religious faith, she expressed her hope for a miracle and wished that her father be able to pass away naturally.

In the closing statements, IN’s daughter communicated her worry that her father would be in pain and expressed similar wishes to her uncle. She said, “it will take weeks for him to pass away, and he will be in pain all the way though. I can’t agree to put my father through something like this. It is up to God to decide my father’s life”.

When asked by the judge whether she would like to travel to the UK should the court rule that it is lawful and in the best interests of IN for treatment to be withdrawn, she answered that yes, she would wish to but was unsure as to how long she would be able to stay. The judge told her that the “Trust would delay starting withdrawal of nutrition and hydration for up to 10 days would you wish to come to England within that period”. 

In the closing statements, it was expressed that IN’s family had not had the opportunity to discuss with IN what he would want for himself in this situation. Though they believe that due to his religious faith and the fact that he was a “fighter”, that IN would not want treatment to be discontinued. 

Judgment

In his judgment, the judge concluded that it was not in IN’s best interest to continue CANH. “He has no prospect of recovery and provision of treatment by way of CANH would continue his burden and delays his death. The burdens of living far outweigh its benefits”. The judgment has subsequently been published in full (here).

Before the hearing ended, the judge said, “may I offer my sympathies to [IN’s daughter] and [IN’s brother] and his wife…I hope that they can all find some peace even in these awful circumstances”.

Reflections

There are a number of things that stood out to me in this case. Perhaps most notably, was the diagnosis of IN, and the unusualness of his condition in that he had remained in a medically stable coma even after several months. I couldn’t help but feel sympathy and sadness towards both the family and the treating staff. As Dr A stated, he found this to be a particularly difficult and distressing decision to make, and of that I have no doubt – though there is no denying that end-of-life decisions are rarely easy decisions to make. 

In other ways, this case was not unlike other cases that I have observed particularly in terms of the wishes, beliefs, and faith of the patient’s family members. Often, families hold out a hope that their loved one will recover even when medical evidence suggests that the prospect of recovery is extremely low. It is not uncommon for families to want to wait for a ‘natural death’ rather than feel implicated in decisions to withdraw treatment. And sometimes the religious beliefs of family members are clearly relevant. In this case, IN’s family held strong religious convictions and believed that death could only be decided by God. Religious belief is a topic that is often present in court hearings, and in discussions regarding end-of-life. While these beliefs can often provide an insight into the values of P, it can also be argued that while it is important to take into consideration, it is not always a defining factor when determining what P would want for themselves.

Although they were not involved in this case, Christian Concern has often provided legal intervention and advocacy in end-of-life cases in the Court of Protection and in the Family Court. In their written evidence submitted to UK Parliament (found here), they state that “Christian Concern has been at the cultural forefront of supporting the right to life from conception until natural death” and “have supported numerous individuals and families where end-of-life issues have encroached on the threshold of what rightly should be labelled euthanasia”. Through their involvement, their ‘pro-life’ narrative is asserted, and while they seek to aid families and individuals, there is also a motivation to influence public policy and legislation and publicise their beliefs.  As we have seen before (see Celia Kitzinger’s blog post and Jenny Kitzinger’s blog post here), there have been instances where cases have been used as a way to promote a broader agenda. 

The topic of a ‘natural death’ is most associated with DNACPR (do not attempt cardio-pulmonary resuscitation) discussions, especially in academic literature. Allowing a ‘natural death’ often refers to allowing someone to die without the use of artificial life-sustaining treatments. However, in some cases in the Court of Protection the argument to allow a ‘natural death’ is used in support of allowing life-sustaining treatments to continue, as we have seen in this case. As a result, there is some debate as to what allowing a ‘natural death’ looks like. Media narratives of death are often focused on the polarising and contentious issues of end-of-life decision-making, for instance, dying naturally versus respecting individual autonomy. This case highlights these debates and shows how a ‘natural death’ may be somewhat of a subjective concept. 

For me, this case highlighted the importance of both advance care planning, which is a process through which you can document your personal values, goals, and preferences regarding future medical care, appoint someone to make decisions for you if you can’t, and – if you want to – you can make legally binding treatment refusals.  Though conversations about death and dying are never easy, it’s important to make sure that you and your loved ones have a plan in place or are aware of what kind of care you would want at end of life. This narrative is rarely seen in media coverage of these cases. In part, this may be explained by the fact that advance care planning is often a personal matter and doesn’t always include dramatic conflicts or disputes that capture media attention. However, as we have seen in this case, its prevalence in discussions involving end of life decisions is undeniable. 

There hasn’t been any media coverage of this case – at least so far.  It’s unfortunate, in my view, that journalists are not bringing cases like these to public attention.  In part, this is because of the reporting restrictions.  Not being able to name the people involved in the case – or even the public body (the Trust) or hospital – has a chilling effect on Transparency. So, I was pleased to notice that the judge addressed the matter of the Transparency Order following the Abbasi case in March this year. As a journalism student, I am concerned that reporting from the courts should be as open and transparent as possible and Abbasi (Abbasi & Ors [2023] EWCA Civ 331) has contributed to that.  he Court of Appeal grappled with the problem of reporting restrictions in serious medical treatment cases and concluded, as noted by Alex Ruck Keene in his Mental Capacity Law and Policy blog, that in future cases “indefinite RROs (at least in respect of securing the anonymity of professionals, rather than the person or their family) will very much be the exception rather than the norm”. 

In relation to this hearing, the judge ruled that the part of the Transparency Order preventing publication of the name of the Hospital and the treating clinicians shall be discharged seven days after IN’s death. Before Abbasi it was usual to see Transparency Orders simply stating that the prohibitions on identifying public bodies, hospitals and clinicians would remain “until further order of the court”.  So, this is an important development for freedom of the press – and in future, the possibility of naming at least the public bodies and the Hospital might result in cases like these being reported and adding to public understanding (see §44-§47 of the approved published judgment).

As always, attending this case was both an upsetting and an eye-opening experience. Observing cases such as this one is helpful both in developing my understanding of the court process and the decision-making process but also in developing an understanding of the impact these decisions and processes can have on those involved, and on the ways in which journalism engages with serious medical decision-making in the court.

Editorial Postscript: In the published judgment, there is a postscript: “I gave this judgment in open court on 21 July 2023. Very sadly IN died in hospital on 24 July 2023. This was before the implementation of the plan to withdraw CANH. I have offered my condolences to his family who raised no objection to this judgment to be published.”

Rhiannon Snaith is an ESRC funded PhD student at the School of Journalism, Media and Culture at Cardiff University. Her research focuses on media representations of decisions about life-sustaining treatment, specifically for those without the capacity to make such decisions for themselves. She has previously blogged for the Project here and here.  You can learn more about her work by checking out her academic profile and her Twitter profile