Decision-making with clarity and compassion: Validity of LPAs and appointment of Deputy

By Clare Fuller, 28th November 2022

As a consultant for Lasting Power of Attorney and an advocate for Advance Care Planning, learning more about the Court of Protection work and processes is important to me. I have attended previous hearings and found the experiences invaluable[i].

This hearing concerned whether the person at the centre of the case had validly appointed his sister and her husband with Power of Attorney. 

Lasting Power of Attorney (LPA) is a legal document that enables a someone to nominate a trusted person to speak for them if they ever lose capacity due to ill health or a sudden accident. There are two different LPAs, one for Health and Welfare and one for Property and Finance.

The key questions in this hearing were: (a) were the LPAs valid and (b) if not should a Financial Deputy be appointed and if so who?

I’ve written previously about “Capacity to make a Lasting Power of Attorney”.  In essence, an LPA is only valid if it is made when a person has capacity:

“To work out whether someone lacks the mental capacity to make a decision, you need to answer ‘yes’ to these two questions: Do they have a mental or brain problem that stops their brain or mind from working properly? Is that problem causing them such difficulty now that they are unable to make this particular decision at the time it needs to be made? Being ‘unable to make this particular decision’ means that the person can’t: understand relevant information about the decision that needs making; keep that information in their mind long enough to make the decision; weigh up the information in order to make the decision; or  communicate their decision – this could be by talking, using sign language, pictures or even just squeezing a hand or blinking.”
LP12 Make and register your lasting power of attorney: a guide

In a key case earlier this year concerning capacity to make an LPA (The Public Guardian v RI & Ors [2022] EWCOP 22 ), the judge helpfully laid out the relevant information that a person needs to be able to understand, retain and weigh if they have capacity.  This information is:

a. The effect of the LPA.

b. Who the attorneys are.

c. The scope of the attorneys’ powers and that the MCA 2005 restricts the exercise of their powers.

d. When the attorneys can exercise those powers, including the need for the LPA to be executed before it is effective.

e. The scope of the assets the attorneys can deal with under the LPA.

f. The power of the donor to revoke the LPA when he has capacity to do so.

g. The pros and cons of executing the particular LPA and of not doing so.

There are two parts to this blog. I’ll first consider issues of access and transparency as they impacted on me as a member of the public seeking to observe a COP hearing, and then (in the second part) I’ll consider the substantive issues before the court.

1. Transparency

On this occasion I was also mindful of the Open Justice Court of Protection work on assessing the performance of the Court of Protection which you can see listed below and read more about here

Before I describe the hearing and what I understood and learned from attending, I will briefly reflect on the ten KPIs identified and can report:

  1. The hearing was listed on @CourtServe.
  2. It was not clear the public could observe.
  3. Partially met, the hearing was remote but the information did not clarify it was by telephone not video link.
  4. Correct contact information supplied on CourtServe and on the First Avenue House websites (and reproduced by the Open Justice Court of Protection Project).
  5. Fully met, I understood the hearing was about decisions relating to Lasting Power of Attorney (see listing below). 
  6. Fully met, it was listed as a “Directions” hearing (see listing below).
  7. Fully met – I received a link to join the meeting via telephone.
  8. Not met.  I did not receive a Transparency Order.  I am basing this blog on my understanding of the ‘standard’ transparency order from previous experience at the Court of Protection hearings.
  9. Fully met, the opening statement by the judge provide clarity on the case, introduced the parties and identified who was representing whom. 
  10. I requested but did not receive a Position Statement (i.e. a statement from the parties which setting out their argument and what they want the judge to do).

I’ll now describe what happened before and during the hearing and what I learned from being present. I’m including the “before” to show how straight forward it can be to attend and what to do – things I wasn’t aware of before my first experiences as an observer.

Before the hearing

I was made aware of the hearing the night before and was able to access the following information from Open Justice Court of Protection Twitter; knowing I had an interest I was lucky enough to receive a direct message alerting me to the hearing, and pasting in the entry from the Daily Cause List for First Avenue House.

Using wording from a previous template I applied via email; I am including the email which can be used and adapted for anyone wishing to attend a hearing.  It’s important to put the words “Observer Request” and the case number and judge’s name in the subject header of the email.  This is because staff are busy and it’s helpful to make it as clear as possible what you are asking for.

At 09:38 I received an email informing me of the dial-in details to attend the telephone hearing. I had previously joined by video conference before, so joining by telephone was new to me; I read that the landline was free to use – however there could be charges associated with using my mobile phone. 

2. The Hearing

Opening 

The hearing began at 10:34 with a welcome from Deputy District Judge Whitfield. There were two other people in attendance (aside from the judge and me):  these were the applicant from East Riding Council (who I will anonymise as Mr Jones), and the respondent who I will anonymise as Mrs Lucy Smith. 

Mrs Smith’s husband (anonymised as Thomas Smith) was noted by the judge to be a co-respondent but currently in hospital and therefore unable to attend.   Judge Whitefield commented that information had been jointly received from Mr and Mrs Smith and confirmed it was acceptable to continue in his absence. Judge Whitfield explained that Lucy and Thomas were attorneys for Steven (the person at the centre of the case, Lucy’s brother)  both for Health and Welfare and for Property and Finance.

The judge proceeded to explain the formalities of the hearing –  namely that it was being recorded and that each of us could state we were in a private location and could not be overheard or disturbed. He asked if it would be acceptable to use first names in his discussions with Mrs Smith, to which she agreed; I will therefore continue in the blog with first names for Lucy and Thomas. The judge suggested it helped to reduce the formality which I understood, however I also felt it could have been appropriate to use first names for everyone rather than the respondents only for greater equality. Neither Mr Jones from East Riding Council nor I were referred to in first name terms, maybe a discussion on this potential power in balance is material for another blog?

Before formally embarking on the hearing, Deputy District Judge Whitfield asked how Thomas was and said that he hoped Thomas continued to make good progress in hospital. I had the impression this was valued by Lucy and it certainly helped create a compassionate atmosphere. 

The questions to answer

The key questions in this hearing were: (a) were the LPAs valid? and (b) if not should a Financial Deputy be appointed and, if so, who?

Deputy District Judge Whitfield proceeded to lay out a summary of the issues at the heart of the hearing.  (Providing this kind of summary meets KPI 8.) I found this helpful and appreciated having the background explained in such a clear manner. He explained that the hearing concerned the “validity of various LPAs and whether a deputyship should be appointed”. He outlined Steven’s history describing him as “approaching sixty, living in rented accommodation and as a person who has experienced lifelong physical and learning disabilities”. 

The judge continued to explain that Steven has made two Lasting Power of Attorney documents (one for Health and Welfare, one for Property and Finance) which were signed in May 2022 but not yet registered due to objections raised by East Riding Council. 

Following a capacity assessment made last year, Steven was identified as having a “basic idea of money”, but no ability to weigh up decisions or communicate with insight. 

Both East Riding Council, represented by Mr Jones, and the two prospective attorneys had previously believed they should act for Steven and indeed that he wished them to.  Deputy District Judge Whitfield noted that Steven is reported to have tendencies leading him to be “easily led” and to provide the answers that he believed to be wanted.

A previous dispute resolution meeting had been held and the judge stated he understood that Lucy and Thomas no longer objected to East Riding Council’s application.

In summary (said the judge):

  • Were the Lasting Power of Attorney documents valid when they were signed?
  • Would an investigation be required? (This would “fall away” if there were no longer objections)
  • Does Steven have capacity to make a Lasting Power of Attorney?

Lucy and Thomas’s historical “lack of confidence” for the Council’s management of Steven’s financial affairs was identified, followed by a hope they were now satisfied “it is appropriate, and in Steven’s best interests, that East Riding take over financial affairs”.

The judge explained there was nothing to preclude “all parties discussing affairs” and suggested “establishing a baseline for discussing Steven’s needs, for example, Christmas presents and winter clothing”. 

Having established that Steven does not have capacity to make an LPA, deputyship was described as a way of protect Steven and anybody else from misunderstandings. I have written in detail about the differences between an attorney and a deputy in an earlier blog and summarise briefly below:

  • CAPACITY: An LPA is made when a person has capacity, a deputyship is made if a person has lost capacity
  • CHOICE: Making an LPA gives a person choice in who can speak for them, a deputy is appointed by a court
  • PROCESS: It is more complex to apply for a deputyship than an LPA
  • TIME: It takes around twenty weeks to set up an LPA; a deputyship takes considerably longer
  • COST: It is more expensive to set up a deputyship compared to an LPA
  • ONGOING COST: There is an ongoing annual cost associated with a deputyship whereas an LPA has a one-off registration cost.

At this point, the judge asked Lucy if she and Thomas would be content that East Riding looked after Steven’s affairs to which Lucy agreed saying, “I only want what’s best for Steven”.

I noted that Deputy District Judge Whitfield stressed there was no “suggestion of impropriety”, and stated to Lucy “I suspect you have a lot on your hands”. This continued to demonstrate compassion that had been displayed earlier in the hearing. 

The formal outcome

The judge summarised the proceedings stating “I formally record the LPAs are invalid and should not be registered, and the application for deputyship for property and affairs is approved”. 

The LPAs were invalid was because Stephen lacked capacity at the time of signing the documents. 

The unexpected outcome

In opening the hearing,  Deputy District Judge Whitfield set out the relevant details. It appeared clear that the issue of Steven’s lack of capacity had already been agreed, this meant that Stephen would require a person (or persons) to manage his financial affairs.  As Steven is unable to make an LPA, a deputyship is required for him; once again this was agreed by all parties at the outset. Following initial disagreement between East Riding Council and Lucy and Thomas, I understood in the opening statement that this had been resolved:  both the respondents were now happy for East Riding Council to act for Steven.

At the outset the hearing appeared straightforward, and whilst the formal outcome was no surprise to me, what I had not expected was to see a Judge checking on a respondent’s welfare. 

I have referred twice already to the compassion shown by Judge Whitfield and this continued to the end of the hearing.

Judge Whitfield gently and sensitively asked Lucy about how she was coping and what support she was receiving.  On hearing that Lucy was coping without help he stated, “you might be entitled to some help and support yourself as his (Thomas’s) carer. Can you signpost Mr Jones?”   To which Mr Jones stated, “I am happy to talk to Lucy after this call.”

What I learned from observing

This was the fifth time I have attended a hearing through the Open Justice Court of Protection project and built on the previous knowledge and confidence I have gained. I know that both information received beforehand and the application process can vary and fully appreciate the drive to set KPIs as minimum standards. As a new observer it can be easy to believe that you somehow “don’t know” how to navigate the system when instead the system is not clear enough to navigate. This is sad because any barriers to attending could dissuade people from attending and work against the judicial aspiration of transparency.

I left the hearing with greater confidence in how to navigate the system, but more importantly, with great respect for seeing compassion in action.

Clare Fuller RGN MSc is a registered nurse with a career dedicated to Palliative and End of Life Care. She is an advocate for proactive Advance Care Planning and provides  EoLC Service Analysis and bespoke EoLC Education. Clare hosts Conversations About Advance Care Planning. She is also a  Lasting Power of Attorney Consultant and director of Speak for Me LPA. Connect with Clare on Twitter @ClareFuller17


[i] Previous hearings I’ve blogged about are: 

Bearing Witness: Anorexia Nervosa and NG Feeding

Lasting Power of Attorney: Across Borders

Capacity to make a Lasting Power of Attorney

Reflecting on Re MW and Advance Planning: Legal frameworks and why they matter  

What happens when Lasting Power of Attorney goes wrong?

Closed Hearings: Submission to the Rules Committee

By Celia Kitzinger, 22 November 2022

Preamble

There’s a sub-committee of the Court of Protection Rules Committee looking at the matter of closed hearings. ‘Closed hearings’ means hearings where one party (and their legal representatives) is excluded by order of the court and may not be told the hearing is even taking place – as happened to the mother in the ‘covert medication’ case we’ve blogged earlier (e.g. Reflections on open justice and transparency in the light of Re A (Covert Medication: Closed Proceedings) [2022] EWCOP 44). There are also ‘closed material’ hearings where some of the evidence before the court is withheld from one party (and/or their legal representatives).

The sub-committee is composed of four barristers who do a lot of work in the Court of Protection: Alex Ruck-Keene KC (Hon), Fiona Paterson, Joseph O’Brien KC and Michael Mylonas KC. Joseph O’Brien was also involved in Re A (the closed hearing case we blogged about earlier) as the legal representative for the Trust.

The subcommittee is preparing a report so as to enable the Vice-President to issue Practice Guidance about what must be taken into account when closed hearings are considered. I was invited to make a submission. What follows is that submission, as sent to the committee on 21st November 2022.

Submission on Closed Hearings by Celia Kitzinger

I am writing this submission in a personal capacity as a member of the public. I draw on my experience of observing 370 Court of Protection hearings as a public observer, and most particularly on my experience of the case of Re. A (Covert Medication and Closed Hearings) [2022] EWCOP 44  (henceforth Re A) – of necessity, because that is my most extensive (and concerning) experience of observing proceedings of which I know closed hearings to have been a part.  Although I draw also on my experience as co-director of two groups (the ‘Open Justice Court of Protection Project’ and the ‘Coma and Disorders of Consciousness Research Centre’), the views expressed here are my own, except when otherwise attributed.

In the aftermath of Poole J’s decision to reveal the fact of the closed hearings in Re A, I have done some research on closed proceedings and ‘closed material’ hearings. I have read relevant case law[1] and also the guidance from 39 Essex Chambers relating to “Without notice hearings before the Court of Protection” (November 2017). I have raised concerns about the role of observers in relation to closed proceedings in four different regional Court of Protection User Group meetings and I’ve benefitted from the responses from lawyers and judges. I have also discussed closed hearings with around two dozen Court of Protection lawyers and with family members of people involved in Court of Protection proceedings.  In trying to get to grips with the ethics of closed hearings – and specifically the ethics of what happened in Re A – I’ve also read some moral philosophy on truth-telling and deception. 

Obviously, what I’ve written here may reflect errors in my understanding of law and practice in the Court of Protection. This is an opinion from an informed ‘outsider’ (not a lawyer) and should be read with that in mind.  I apologise for anything that sounds naïve or insulting or just plain wrong. I’ve done my best to be a ‘critical friend’ to the Court.

The key points of my submission (explicated below) are as follows:

1. Reactions to Re A (both from lawyers and from the public) clearly demonstrate the need for guidance on closed hearings– and it needs to be outward-facing.

2. Guidance needs to explain the exceptional circumstances under which judges can discard the ordinary rules of judicial enquiry – with concrete examples drawn from case law, and illustrating ‘good’ and ‘bad’ practice in decision-making about closed hearings.

3.  There should be reporting and monitoring of closed proceedings and closed material hearings.

4. Closed hearings should be listed as such and open, in principle, to observers.

5.  The Guidance should say that judgments from closed hearings should normally be published on publicly available sites (e.g., National Archives).

6.  Guidance needs to deal with how to manage open hearings running in parallel with closed hearings – ideally by stating that this shouldn’t happen (certainly not over periods of months or years).

7.  The Guidance should address (and encourage lawyers and judges to address) moral complexity – in particular, the moral costs associated with making the right decision. 

8.  The Guidance should state that observers must not be admitted to ‘fake’ hearings (if they continue to happen) without proper briefing.

9. The Guidance should emphasise the need to inform the excluded party about closed proceedings as soon as possible (not least, to enable an appeal).

10.  Some remaining issues….

1. Reactions to Re A (both from lawyers and from the public) clearly demonstrate the need for guidance on closed hearings– and it needs to be outward-facing

Before my involvement in Re. A, I did not really understand  – and nor, it seems did some COP lawyers – that there were ‘closed’ proceedings (as distinct from merely ‘private’ ones) in the Court of Protection.  It had not occurred to me that parties might be deliberately excluded from hearings by court order, or that it could ever be fair and just to do this. The events of Re A therefore came as a shock – and as a learning experience. In retrospect, it seems as though I should have known about closed hearings, since there is case law publicly available – but I had not stumbled upon it, nor had I fully appreciated the import of some judicial comments to which I’d been exposed which (now) I recognise as referring to closed hearings.  The different terminologies used (‘without notice’, ex parte, closed material proceedings, etc) has acted as a barrier for me in making sense of it all.  Since some lawyers, as well as members of the public, tell me they were unaware of closed hearings (in the sense intended by this subcommittee),  it would be helpful for Guidance to flag up that closed proceedings (as defined in the subcommittee’s terms of reference) are a part, albeit an exceptional part, of Court of Protection practice.

The polarised reactions from lawyers to the events revealed in Poole J’s judgment in Re A also clearly demonstrate the need for Guidance. Some lawyers  – those not previously aware of closed hearings – saw the closed hearings as unethical, insupportable and even unlawful. One COP lawyer described the events in Re A as “breath-taking“: “Managing a case in this way,” he wrote, “requires either total ignorance or total disregard for our most basic constitutional principles”.  Another lawyer wrote: “Serious questions raised about open justice, of course. But this is surely an Article 6 violation. The party excluded from the closed proceedings litigated from *a place of ignorance engineered by the court*”.  

Other lawyers appeared to minimise what had happened.  Some compared the exclusion of A’s mother from the closed hearings to s.49 orders or to disclosure orders against GPs (the relevant comparison being that those organisations/people are also often not in court when orders are made against them). Some pointed to the ‘successful outcome’ of the proceedings as offering total justification for everything that was done along the way.  

Others spoke of “discomfort” and feeling “uneasy” or “queasy” about events in Re A without being able fully to articulate why – in one case, despite the experience of having been involved in what the lawyer described as a “wholly justified”decision to hold a closed hearing enabling P to be transferred from an abusive partner to a place of safety.  

Formal Guidance would provide lawyers (and judges) with a scaffolding of facts, law and relevant considerations to take into account when engaging with closed hearings in future. It would enable them to: identify the conditions under which closed hearings are lawful and necessary; prevent too easy an acceptance of the need for closed hearings; and encourage reflection on the challenges presented by closed hearings and how to manage them.

There is also a clear need for the Guidance to address the concerns of members of the public (including people involved in COP proceedings). 

There are two broad aspects to public concern with closed hearings: (1) the procedural irregularity involved in excluding a party (often a family member) from the proceedings; and (2) the substantive outcome of the hearing in terms of declarations and orders made, which can be perceived as unfair or even as human rights violations. 

These two concerns are inter-related because there can be a perception that an outcome perceived as unjust has come about as a consequence of closed proceedings, i.e. that if there had been a ‘fair’ hearing at which the excluded party had been able to participate (tell their ‘side of the story’, cross-examine witnesses etc)  the judge would have made a different decision.  

In addition, the Re A case in particular has raised (or underscored) public concerns about practices seen as involving ‘deception’ – both by lawyers and by the judiciary.  This arises in particular from the fact that, in April 2022, there was an open hearing before HHJ Moir (with a public observer) at which A’s mother was left in ignorance of highly salient decisions made in an earlier closed hearing – decisions which impacted upon her application in the open hearing. 

The mother applied for her daughter to return home in part on the grounds that professionals had failed to get A to agree to hormone medication and that she (the mother) would be more likely to be able to do so in the home environment[2]. This was also the gist of her application in the hearing before Poole J. Both applications were based on false premises. Having been told that her daughter was still refusing hormone treatment, she assumed (as I believe she was meant to assume, and as her legal team and the public observer also assumed) that her daughter was not receiving hormone treatment. Her position statement claims for example that “at 23 years old, [A] has not attained puberty” (§4) and that “[A] is not taking her endocrine medication, her future remains at risk…” (§12) (Position statement for A’s mother dated 16 September 2022).

At the April 2022 hearing, all other parties, and the judge, knew that the mother’s assumptions that her daughter had not received hormone medication and had not gone through puberty were not true. They did not correct her. 

The mother and her legal team were not told that A had been covertly medicated, or that she had gone through puberty, until the first day of the open hearing in September 2022. 

As a result of learning the true facts at the beginning of the September 2022 hearing, counsel for the mother described the mother’s position statement as “otiose” (i.e., as serving no practical purpose, lacking effect, pointless, useless, futile) and the mother reluctantly withdrew her application for her daughter to return home. 

Up until that point, information had been kept from her such that she participated in an open hearing not knowing about the closed hearings from which she’d been excluded and not knowing material facts about the case. 

Learning about this episode is very disturbing for family members currently involved in Court of Protection cases.  It raises the question “could something like this be happening to us?”.  

It would be helpful for the Guidance to consider ways in which the taint of deception could be removed, as far as possible, from cases involving closed hearings and to recognise and seek to minimise the moral injury they can cause.  By ‘moral injury’ I mean the experience of “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations” and “may be deleterious in the long-term, emotionally, psychologically, behaviorally, spiritually, and socially[3].

I hope those who produce the Guidance will – in selecting its language and content  – take account of the fact that members of the public are likely to read it.  While not addressed to us, it should be written in the knowledge that we are part of its audience, and that our understanding of what it says is likely to influence our confidence in the Court going forward.

2. Guidance needs to explain the exceptional circumstances under which judges can discard the ordinary rules of judicial enquiry – with concrete examples drawn from case law, and illustrating ‘good’ and ‘bad’ practice in decision-making about closed hearings 

The Guidance should reiterate that the fundamental principles of judicial inquiry ordinarily demand that all parties are able to participate in proceedings, and that justice should be done openly at a fair hearing, on the basis of evidence made known to all parties. 

This will reassure the public.  

It will also serve as a useful alert to some lawyers.  I’ve been alarmed by the apparent readiness of some of those with whom I’ve discussed Re A to advocate for departure from the ordinary principles of judicial inquiry in order to achieve the ‘right’ outcome without (in my view) sufficient consideration of alternative courses of action or of the moral costs associated with closed hearings. 

The Guidance needs to reference the Court of Protection rules that permit the court to exclude parties from hearings, and to withhold evidence from parties – highlighting that this can only be done where it serves the overriding objective of promoting P’s best interests in circumstances where  “justice would be defeated if notice were given” (§5 COP PD 10B).  

The Guidance should explain the sorts of circumstances under which closed hearings are permitted (or required), making clear the burden of justification lies with those who claim that these ordinary principles of judicial enquiry do not, in the particular circumstances of the case, serve the ends of justice and should be discarded (paraphrased from Lord Devlin in Official Solicitor v K [1965] AC 201 (p. 238)).

Concrete case studies should be included in the Guidance. It would be helpful to include cases where closed hearings were considered and rejected, as well as those where closed hearings went ahead. It should also include those where closed hearings resulted in bad decisions (e.g. the case of Aamir Mazhar[4]) as well as those where closed hearings were clearly the right thing to do and led to positive outcomes.

3.  There should be reporting and monitoring of closed proceedings and closed material hearings 

The Vice President has said that closed hearings are  “extraordinarily rare[5], but nobody seems able to provide information about exactly how many there are, or the circumstances leading to them.

Here’s my attempt to come up with some rough idea of how rare, or frequent, closed hearings might be.  In the course of observing 370 hearings, across approximately 300 different cases in the Court of Protection, and requesting without success access to around 700 more,  I’ve become personally aware of four closed hearing cases.  In two of these cases,  I observed a hearing at which the judge said explicitly that the case had also involved an earlier closed hearing: one was the open hearing in Re A,  the other was an open hearing that followed a closed hearing in Hull City Council v A & Ors[2021] EWCOP 60.  I sought access to, but was not admitted to the other two hearings.  One was the hearing before Hayden J that was subsequently appealed (In the Matter of P (Discharge of Party) AA [2021] EWCA Civ 512): in that case I was admitted to the video-platform only for the 5-10 mins it took for counsel to make their arguments (accepted by the judge) that the hearing should be held in private, and then I was asked to leave. The fourth closed hearing is one I only became aware of much later. I was refused permission to observe a hearing (randomly selected from the listings) before HHJ Haynes on 16 June 2020 in Leeds County Court: I subsequently identified it as the hearing that became the subject of an appeal about closed materials in KK v Leeds City Council [2020] EWCOP 64.[6]  So my own experience gives me a ballpark figure of maybe 4/1000 or 0.4%. This is likely to be an under-estimate[7].  In any case, 0.4% is rare, but not (in my view) “extraordinarily” so, especially given the large number of cases heard in the Court of Protection.

It would be helpful (and reassuring for family members of P) for the Guidance to ask that closed hearings, and closed material hearings, should be formally logged as such with some responsible administrative body within the Court of Protection so that their frequency can be known and reported annually  (e.g., in the form of “there were X hearings in the COP during 2023 concerning Y cases,  of which Z were closed proceedings or closed material hearings….. etcetera”, plus some summary detail about the features of the case that resulted in the closed hearings, and their outcome).

4. Closed hearings should be listed as such and open, in principle, to observers 

It seems that some closed hearings are not in fact listed.  In his judgment in Re A, Poole J reports his decision not to list the first closed hearing before him, and he acknowledges that: 

In retrospect it might have been possible to list the case without a case number or with a new case number created for the specific hearing, without any identifying names or initials to enable the listing to be linked to any previous open proceedings, and to make a reporting restrictions order at the hearing to prevent any communication or publication about the hearing (at least not until further order)” (§9 Re A). 

I support Poole J’s suggestion.  I recommend creating a new case number for a (first) closed hearing in a case which avoids linking the listing to previous open proceedings, and using the same closed case number for all closed hearings in the same case (thereby enabling identification of subsequent closed hearings in the same case).   I recommend clearly identifying the hearing as a ‘closed’ hearing in the listing (e.g. by stating “Closed Hearing” in the listing), thereby supporting the reporting and monitoring exercise advised above, and enabling journalists and the public to identify closed hearings as such.

Closed hearings should not normally be held in private.  There would be huge benefits in permitting observation of closed hearings by journalists and members of the public, subject to appropriate reporting restrictions and publication embargos.  One reason for having observers in court is to ensure that justice is seen to be done, to “keep the judge, while judging, under trial” and to “guard against improbity”.  This is arguably more important in closed hearings than in ordinary hearings attended by all parties. 

Obviously, the benefits of transparency would need to be considered on a case-by-case basis and balanced against the risks attached to having observers in court. I am simply suggesting that there should be no ‘in principle’ exclusion of observers from closed hearings.  And for those undertaking this balancing exercise, I draw attention to the fact that breaches of transparency orders, reporting restrictions and publication embargos have been very rare over the course of the last two and a half years, despite the huge increase in the numbers of observers in the Court of Protection, and that compliance with reporting restrictions has been maintained by both journalists and members of the public over long periods in other cases (e.g. more than 2 years in Hinduja [2022] EWCA Civ 1492)

5.  The Guidance should say that judgments from closed hearings should normally be published on publicly available sites (e.g. National Archives)

It is very important, in my view, that when judges discard the ordinary principles of judicial enquiry, that they publish judgments explaining why they have done so, and give a full account of the substantive issues in the case, the decisions they made, and reasoning behind those decisions.

This should be the norm for all closed hearings – but of course it is especially important when closed hearings are conducted in private.  As Poole J said in relation to the closed hearing in the Hull City Council case:

Without notice orders of the kind I have made in this application are exceptional and I consider necessary to set out the reasons for making them in a published judgment, suitably anonymised to protect A’s identity. By previous orders the proceedings have been conducted in private therefore they were not open to members of the public. Nor did any journalist or blogger attend. It is important that when the workings of the Court of Protection are carried out in such circumstances and powers are exercised of the kind I have exercised in this case, the court’s processes and reasoning are at least subsequently laid open in a published judgment.” (§2 Hull City Council v A & Ors[2021] EWCOP 60, Poole J)

The fact that some judgments from closed hearings are published means they can be evaluated to assess the extent to which it was necessary conduct closed proceeding (to protect P from harm and ensure P’s best interests).  Those I’ve read do support the need for closed proceedings: they’ve been concerned, for example, with physical, psychological or sexual abuse from the excluded party, or the risk of P’s removal to a foreign country in a forced marriage case. In addressing these concerns, judges act in accordance with Articles 16 and 19 of the Convention on the Rights of Persons with Disabilities – the duty upon States to protect those with disabilities from exploitation, violence and abuse, and to secure their right to independent living, respectively. 

These bases for “discarding” ordinary principles of judicial enquiry have been set out clearly in two judgments in particular:

(i) In Hull City Council v A & Ors [2021] EWCOP 60 (before Poole J), the protected party (A’s) son (her main carer) was excluded from a hearing at which an order was made to remove his mother from his home and transfer her to residential care. Her son has a long history of criminal activity including multiple convictions for supplying drugs and for assault.  He had obstructed all attempts by social workers and others to check on his mother’s safety, health and welfare by refusing access to the home. He was preventing  any meaningful contact with A inside or outside her home by the other parties to the case. The judge ruled:  “I am satisfied following the hearing on 2 November 2021 that if he were to have notice there would be a substantial risk that he would use the time afforded to him to obstruct A’s planned removal and conveyance. He would be likely to take steps to frustrate the purpose of the order. Those steps could put A at risk of harm. I am satisfied that the exceptional course of proceeding without notice to him is required in this case.”

(ii) In KK v Leeds City Council [2020] EWCOP 64 (an appeal heard by Cobb J against a decision by HHJ Hayes QC), the protected party (DK)’s maternal aunt (KK, formerly her main carer and the person she calls “Mum”) applied to be joined to proceedings and was refused party status by the judge at first instance, and then at appeal. As a teenager, DK had been a victim of child sexual exploitation and made allegations against KK’s husband and son of sexual abuse; these were investigated by the police over a period of 18 months (during which time KK and DK had no contact) before the police decided to take no further action. She has ongoing exposure to sexual exploitation and trafficking. The local authority alleged that KK’s relationship with DK exhibits elements of control and said that  “KK having party status would perpetuate and facilitate this control”.  Some of the evidence for this was in ‘closed materials’ which neither KK nor her legal team were allowed to see. Revealing these materials or joining KK to the proceedings would prevent her from “expressing her true wishes and feelings”, “undermine the process of ensuring her effective participation in these proceedings” and “interfere with DK’s right to respect for her private life”.

These judgments provide evidence of the need for closed hearings and address the basis on which decisions to conduct them were made. This is essential for public confidence in the law.  They also set out the decisions made and the reasoning behind them. 

There is no published judgment in Re A concerning the decisions made by HHJ Moir, at a closed and private hearing on 25 September 2020, to hold closed hearings and to initiate covert medication without the mother’s knowledge.  

I asked for the judgment from this hearing, or a transcript of it, to be published when I attended the hearing before Poole J as an observer on 21st-22nd September 2022. Although Poole J arranged for publication of another of HHJ Moir’s judgments in this case (from an earlier hearing at which she had declared hormone treatment to be in A’s best interests), his judgment made no reference to the crucial ‘closed’ hearing at which the decision was made that this medication should be given covertly and concealed from A’s mother. I emailed Poole J (via his clerk) on 12th November 2022 reiterating my request: 

“Given the draconian nature of this decision, made without the mother’s knowledge, and given the human rights implications that flow from it, it seems only right and proper that it should now be published so that the public (whose confidence in the COP’s judicial process may have been shaken by this episode) can understand the basis on which this decision was made…. If there are difficulties with publishing it as a formal judgment now that the judge involved has retired, can a transcript of the recording of the hearing be made public please?”.  

In his judgment at a subsequent hearing (on 14th November 2022) the judge authorised a transcript of this hearing and said that it should be made publicly available on the National Archives. This all took considerable persistence on my part and I’m not at all sure that concrete plans would ever have been made to publish this judgment without my involvement.  

My involvement in getting this transcript on the road to publication (it’s not there yet, and I will pursue it) shouldn’t have been necessary. The Guidance should say that all judgments from closed hearings (or in cases like this one, the transcript of the closed hearing) should normally be published – with redactions if necessary – unless there is some compelling reason why they cannot be.

Leaving aside, for a moment, concerns about the procedural issues associated with closed hearings, there is also the issue of the  substantive decisions made by the court: to deprive P of her liberty contrary to the wishes of both P and her mother; to use covert medication over (so far) a two-year period; to impose draconian restrictions on contact between mother and daughter.  Whether or not closed proceedings had been involved, this is the sort of case that raises fundamental issues of human rights, and I would want to see it published. 

In discussion with lawyers and others, there has been a tendency to conflate the question of whether or not it was right to conduct closed proceedings with the question of whether or not it was right to authorise covert medication etc.  These matters are clearly connected, but also distinct.

Since the transcript of HHJ Moir’s hearing of 25th September 2020 is not yet available, I am not currently in a position to consider what can be learnt about closed hearings from the way in which HHJ Moir conducted the proceedings. Without access to the facts at the time, and the reasoning of the judge, I cannot assess whether or not (in my view) the decisions she made were appropriate, proportionate and justified in the circumstances of the case. Or alternatively whether there might have been alternative (less coercive) means of pursuing the best interests of the protected party.  I have been somewhat surprised at how rapidly others (also without benefit of the 25th September 2020 transcript) have felt able to make a judgment one way or the other.  

I hope that the Guidance that eventually materialises as a result of the work of the subcommittee will consider lessons that can be learnt from the hearing of 25th September 2020, once the transcript is available.

6.  Guidance needs to deal with how to manage open hearings running in parallel with closed hearings – ideally by stating that this shouldn’t happen (certainly not over periods of months or years)

Poole J states the facts of what happened in Re A in his judgment (§86): “Open proceedings have been held in parallel with closed proceedings but information and material which was highly relevant in open proceedings was withheld from a party, B, and her legal representatives, who did not know that any information or material had been withheld”. 

These ‘open’ proceedings have been widely understood by members of the public to have been ‘fake’ hearings, whose only purpose was to disguise from the mother what was going on. This has led to concerns about deception in the Court of Protection.  My exposure to a ‘fake’ hearing (attended by Claire Martin as a public observer) has led me reluctantly to conclude that members of the Bar and the judiciary have a more flexible approach to truth-telling than I had previously believed.

From my reading of case law, it seems that running open hearings in parallel with closed hearings as was done in Re A is rare (perhaps unique to this case) – especially over such a long time-span (two years).  But I don’t know this for sure, since I don’t know whether other cases have simply not been published.

In my view, the Guidance should explicitly advise against running open and closed hearings in parallel. This is because when closed hearings concern matters of central significance to the open hearings, and their existence and/or subject matter are not revealed in the course of the open hearings, this is very likely to result in a perception of ‘bad faith’ from the court  – both from those excluded from the closed hearings, and from public observers.

One deeply regrettable outcome of Re A has been the opening up of a gulf between the legal view (or a legal view) and the public view of what happened in the open hearing (before HHJ Moir) in April 2022, attended by an observer from the Open Justice Court of Protection Project, Consultant Clinical Psychologist, Claire Martin.  

From the legal perspective (at least as articulated in court in the September 2022 hearing) nothing took place that should lead us in any way to doubt the court’s commitment to truthfulness.  In the course of Poole J’s hearing, my own dismay that public observers were (in my words) “misled” by the court was either denied outright (“nobody was misled”, counsel for the Trust) or reformulated to avoid any implication of deception: we were simply “under a misapprehension”, said the judge, claiming that the verb “to mislead” implies saying things that are untrue, as opposed to omitting to speak of things that are true. I found this disingenuous.  Most dictionaries include in their definitions of “mislead” omissions designed to create a false impression. 

There is – as my subsequent research has revealed – a debate in moral philosophy as to whether creating and maintaining a false impression (without explicitly speaking untruths) constitutes “lying” or not, and about the circumstances under which this behaviour might be justified, and the morality of equivocation. On the basis of that literature, I am confident in asserting that it is a defensible proposition to say that the court “misled” A’s mother, her legal team, and the public observer in the open hearing  – and that this was less than honest, less than truthful. This is also the view of many members of the public who’ve used terms like “charade”, “sham hearing”, “fake hearing”, “mock hearing”, “show trial” and “smoke and mirrors” in relation to the open hearings the mother was involved in, conducted under the shadow of the closed proceedings from which she was excluded.  The member of the public who attended the April 2022 hearing expresses it this way:

One key concern I have is the parallel mock hearings. I don’t see how this can ever be defended. It’s duplicitous as well as wasteful. It sets up a situation where you have to lie more and more to cover the original tracks.  If closed hearings are allowed, I think the system has to work out a way of handling additional applications from parties who have been excluded – in this case it seems they decided that they had to go ahead otherwise their cover was blown. This just does not seem befitting of a serious judicial system to me! I think my view would be that if an excluded party makes a subsequent application, then they have to be treated fairly and if the hidden information is material to the hearing for that application, they must then be informed about and included in closed hearings.” (Claire Martin, public observer at the April 2022 hearing in Re A)

Deception may sometimes be a necessary moral cost of acting in the best interests of the protected party (see below), but this doesn’t change its status as deception. 

It’s not simply my perception that the court has misled us, but also its denial that it has done so, that constitutes the moral chasm I now experience between my position and that of the court. It may be that there is an unbridgeable difference between us in relation to the ethics of truth-telling, but that difference could at least be acknowledged and some attempt made to deal with its consequences.

7.  The Guidance should address (and encourage lawyers and judges to address) moral complexity – in particular, the moral costs associated with making the right decision 

Many people in England and Wales share the court’s commitment to justice being done and being seen to be done: to fair and open hearings, with all parties on an equal footing and decisions based on evidence made known to all parties. This seems to accord with a widespread view of ‘natural justice’.  When courts depart from these fundamental principles of judicial enquiry, people can feel angry and dismayed at what they experience as potential injustice and abuse of power. This is a good thing.  It would be far more troubling if nobody cared when the court discards fundamental principles of judicial enquiry.

When courts discard the fundamental principles of judicial enquiry they do so because they believe that, in the individual facts of a case, those principles impede justice.  This is a weighty and challenging decision to make: there is a cost either to the procedures understood to constitute justice, or to a just outcome.  This places the court in a moral dilemma such that whatever course of action the judge decides upon has moral costs.  The fact that a decision may be the right one (or the ‘least bad’ under the circumstances) does not obviate the harm that may also be caused. It is in the nature of moral dilemmas that there are moral costs to making good decisions, and those who bear the burden of those costs can justly claim that they have been wronged. 

In the case of closed hearings (even when this is the right thing to do), there is harm done  to the excluded party.  Judges have recognised this, for example by highlighting the importance of considering – before granting a ‘without notice’ hearing – the impact it has on “… the rights, life, and emotions of the person against whom it is granted” (§41 B Borough Council v S & Anor | [2006] EWHC 2584 (Fam).  I can only imagine the sense of moral outrage, violation, and fury that being excluded from a closed hearing about a loved one would engender in me.

When a party’s legal team is excluded from closed hearings and not informed about their existence (as in Re A), they too can feel wronged. They may feel victims of some version of ‘justice’ quite unlike the ideal they signed up to when they chose to become lawyers. It can be corrosive of their professional identity and sense of their own professional efficacy. One lawyer who’d been refused permission to view ‘closed materials’ told me how frustrated he felt about this, saying he still couldn’t understand (some years later) why this refusal had been necessary. A couple of other lawyers with whom I discussed the Re A case  told me that they would not expect ever to be placed in the position of counsel for A’s mother because their reputation means ‘nobody would dare’ to (as one put it) ‘pull the wool over my eyes – and anyway I’m sure I’d see through it’.  What does this perspective mean for those lawyers who have been excluded from hearings or from closed materials, and (if this has been kept secret from them) who have not divined what has been going on? The implication seems to be (and these lawyers may feel) that they have failed in their duty to their clients, that they lack professional acumen or expertise, that they forfeit the respect of colleagues – not just those who excluded them from a closed hearing, but those in the wider community of the Bar. In Re A I saw in the reaction of counsel for A’s mother (in court in September 2022) some indication of the moral injury he felt had been done to him as a professional[8].

I think there is also a moral cost to the lawyers included in closed hearings and to the judges who hear them  – especially when (as in Re A) there is secrecy about those proceedings. They may well believe that they are doing the right thing, and that their course of action is the only way P’s best interests can be secured, but it’s possible at the same time to feel regret that secrecy and deception are the price to be paid for doing the right thing in these circumstances.  Avoidance of truth-telling can harm the person doing it even when they are acting for benevolent reasons (e.g. studies of moral stress experienced by caregivers who validate a dementia patient’s reality at the cost of truth, e.g. that her spouse is dead and won’t be coming home for tea[9]).  Empirical research finds a range of  morally self-reassuring strategies people use to disregard or minimise the moral costs of engaging in the right action – including, in the case of dementia carers, adopting a consequentialist position (‘the end justifies the means’) – a moral-cost-evasive approach that can function to avoid moral ambiguity – and characterising their actions relatively benignly as “white lies” or “colouring the truth”,  “manoeuvring around the truth”,  “not out-and-out lying Practitioners have produced guidance for lying to dementia patients[10].  Lawyers and judges are heavily invested, of course, in a professional identity involving honesty and rigorous regard for the truth: I suspect that explicit acknowledgement that they are less than honest on occasion is challenging.

Some theorists have drawn on philosopher Bernard Williams’ analysis[11] of what he calls the ‘moral remainder’ in considering judicial approaches to complex moral decisions.  It’s based on the observation that even right decisions can cause harm (albeit less harm than the wrong decision).  To take the famous ‘trolley problem’[12] example, if I divert a runaway tram or trolley that is on course to collide with and kill five people down the track, so that instead it kills just one person on a different track, this may well be the right decision (I’ve saved four lives), but one person who would otherwise have been alive is now dead because of my decision.  Bernard Williams uses the phrase ‘agent regret’ to describe the emotion that gives expression to the fact that one has committed a wrong despite the fact that one’s actions were overall not mistaken.  “Shame, regret, guilt,  remorse for those wrongs can be felt by people who did the right thing – and can be appropriate responses to the moral harm caused in pursuit of the right thing[13].

The Guidance should support moral literacy by addressing the fact that in complex moral dilemmas it may be necessary to recognise that acting for the best does not always yield a morally clean result.  It’s appropriate, then, to discuss how to manage the moral harms that result from good decisions.

8.  The Guidance should state that observers must not be admitted to ‘fake’ hearings (if they continue to happen) without proper briefing.

My strong view is that hearings like the April 2022 hearing (widely described as a ‘fake’ or  ‘mock’ hearing) should not be part of Court of Protection practice.  As one case manager (also a COP observer) said, this kind of “masquerade” is “degrading to those involved”.  If, in future, these kinds of hearings are avoided, then there is no risk of public observers finding ourselves in the invidious position we experienced in Re A.

If they are to be accepted as part of Court of Protection practice, then admission for public observers should be contingent on full disclosure of the facts from the court, along with the issuing of a Reporting Restrictions Order and/or publication embargo.

I struggle to find any justification for admitting an observer, without any briefing, to the April 2022 hearing before HHJ Moir. It must have been obvious to counsel and to the judge (if they had given it a moment’s consideration) that the observer would not be able to write an accurate account of the case. It made a mockery of transparency to admit her.

This is how the observer concerned expresses her view: 

Allowing a public hearing to proceed under these circumstances and admitting me as a public observer makes chumps of me, the mother and her legal team (and the public reading the reports) really – and apart from the serious consequence of loss of trust in the system, I’d also say that the cost and utter waste of time for everyone involved is indefensible.” (Claire Martin, observer April 2022 hearing)

The suggestion has been made that excluding an observer might have alerted counsel for the mother that something was awry:  “… if I was acting for a party and the judge specifically determined that a hearing take place in private, and then excluded observers… then I’d probably wonder why – which might have led me or my client to wonder if there were things happening we were not told of… not easy” (COP lawyer).  If the observer was in fact admitted for that reason, she was being used (as Daniel Cloake suggests in his blog post covering the first day of the hearing before Poole J), as “some kind of prop to add an air of legitimacy to an otherwise compromised application”.

The reverberations of admitting an observer to this hearing (without properly briefing her and serving a Reporting Restrictions Order) are far-reaching and deeply unhelpful to us as observers, to journalists, to members of the public more broadly, and to the Court of Protection itself.

It’s caused harm to those of us actively running the Open Justice Court of Protection Project, leading us to doubt the value of our work.  Not only did we publish a misleading account of a case but also it was an account which promoted the version of events the court wanted the mother to believe – thereby making us complicit in the court’s deception without our knowledge or consent. 

Moreover, our blog post could also have (inadvertently) jeopardised the whole endeavour in which the court was engaged in pursuit of A’s best interests, because it raises the matter of covert medication.  In our blog post Claire Martin wrote: “I don’t know whether or not the options of covert medication (or restraint to ensure treatment) have been considered. (They may have been considered in one or more hearings that we missed).” There is no evidence that the mother in this case read our blog – but had she done so, this could surely have alerted her to a possible scenario in her own case.  The court should never have created a situation in which this could arise.

This whole episode has led to scepticism, from journalists and from the public, about the court’s professed commitment to transparency:

When details are hidden rather than being subject to reporting restrictions, it shakes the confidence of observers and reporters in the whole system” (Tristan Kirk, journalist)

How can I trust that any hearing I attend isn’t tainted by having secret, covert hearings going on ‘underneath’ the ones I observe?’ (Louise Tickle, journalist)

From the perspective of transparency, admitting us to a hearing at which salient facts are concealed from one of the parties and from us, such that we will inevitably form a false impression of the case, is far worse than not admitting us to the hearing at all.  It’s a form of ‘double-crossing’.  The presence of the observer in court – the very thing that is supposed to guarantee transparency – becomes instead a source of misinformation and false news. It runs directly counter to the purpose of having observers in court in the first place.

Family members involved in Court of Protection proceedings often tell us that they believe that having an observer present will ensure that the judge “behaves himself” and “doesn’t do anything wrong – because you’ll be watching!”  We know they have found some comfort from having someone independent and impartial as a witness to their story.  They’ve reported that the judge was “fairer” to them because observers were there and commented that, without observers,  judicial unfairness is “unlikely to be found out[14].  And in writing about our Project, we have often quoted Bentham” “Publicity is the very soul of justice. It is the keenest spur to exertion, and the surest of all guards against improbity. It keeps the judge himself, while trying, under trial”.

In future, we will have to tell P and their family, when they approach us asking for someone to observe their hearings, about our experience in this case.

When members of the public come to believe that people in positions of power are not dealing honestly with us, we become disaffected not only with those individuals (judges and lawyers) but also alienated from the institution they represent.  The way this hearing was managed was an own-goal for the Court of Protection.

The Court of Protection needs to take steps to ensure that nothing like this ever happens again.  

9. The Guidance should emphasise the need to inform the excluded party about closed proceedings as soon as possible (not least, to enable an appeal)

The Guidance needs explicitly to address the importance of determining, before or during the course of a closed hearing, when and how someone (who?) is going to inform the excluded party that the closed hearing has taken place and its outcome.  

In Re A, the excluded party and her legal team had not been informed two years later, and it took the intervention of a new (Tier 3) judge to ensure that she was so informed – apparently (as I understand it) without this having been a position put forward by any of the other parties.

Re A is an unusual case on its facts.  In much of the case law, the excluded party seems to have been informed very quickly (within hours or days of the hearing) – not least because the most common reason for closed proceedings seems to be the removal of P from the excluded party’s home, meaning that they discover the existence of the court order quite promptly in any case.

Earlier guidance (from 39 Essex Chambers) specifies that: “Those who obtain ex parte relief are under an obligation to bring to the attention of the respondent at the earliest practicable opportunity the materials on the basis of which the ex parte injunction was granted… The obligation involves giving proper information about what happened at the hearing. Representatives should respond forthwith to any reasonable request for information about what took place.”

It’s not clear to me what “the earliest practicable opportunity” might have been for informing the excluded party in Re A.  It would be helpful for that to be considered and addressed in order that any future cases with similar features can benefit from lessons learnt.

One consequence of not informing an excluded party about decisions made in closed proceedings is that they are not able to appeal the judgment in a timely manner.  This seems fundamentally unjust.  It distinguishes this case from other cases (e.g. In the Matter of P (Discharge of Party) AA [2021] EWCA Civ 512) which is an appeal consequent upon a first instance judge having informed a party of her exclusion from a hearing, thereby enabling an appeal against it).

10.  Additional issues to consider

10.1  A Tier 3 judge? Would it have helped if Re A had been referred to a Tier 3 judge sooner? Should the guidelines indicate the level of complexity at which such referral is required? (In this case the fact that it concerns what used to be labelled ‘serious medical treatment’ seems on its own, to merit a Tier 3 judge.)

10.2. Would it help to have some kind of ‘Special Advocate’ (s.9 Justice and Security Act 2013) to represent the interests of the excluded party?  I recognise that existing guidance from 39 Essex Chambers suggests that the judge should be provided with “a brief account of what the applicant thinks the respondent’s case is, or is likely to be” (X Council v B (EPO) [2004] EWHC 2015 (Fam), [2005] 1 FLR 341, [53], Charles J).  Based on my experience of Re A,  however, I have little confidence that this would work, or that the excluded party would feel that her interests were protected by this.  This opinion is based on the way in which the excluded party was addressed in court in an earlier hearing  (“You are making up all of this in order to support a return home…. This is a ploy by you… You’re making this up aren’t you… You are fabricating a story…This shows a level of deviousness that you cannot be trusted in terms of contact…” Hearing of 26 May 2020, Re A). 

10.3 What should people do if they think they may have been excluded from closed hearings but nobody has so informed them? I did not receive any communications from family members of Ps who were able to report having been excluded from proceedings or denied access to closed materials. Some speculated that there might have been hearings of which they were unaware and pointed out that I was asking an impossible question when seeking information about hearings from which they’d been excluded and the existence of which had been kept secret from them. They asked what they should do to find out if secret hearings had occurred.  (I suggested asking the judge a direct question:  “were there hearings I was excluded from?” – I don’t know if that was a good suggestion or not?)

10.4  Excluding P: The terms of reference for this subcommittee specifically exclude consideration of “hearings which take place without the knowledge of P, but with the knowledge of P’s litigation friend”.  Although I circulated the terms of reference with my call for feedback, the single most frequent response from family members concerned exactly this scenario. Family members were concerned when P wasn’t told about hearings: “She is totally unaware of hearings and what is being said about her” (Mother of P).  “She’s supposedly the applicant in this case, but nobody has even told her the hearings are taking place” (Daughter of P).  It was reported that P’s legal representation was inadequate or misleading.  “The lawyer supposedly representing her hasn’t even met her, and has no idea what her views are” (Daughter of P); “Her Barrister has no thoughts other than backing the Local Authority, even regarding serious impositions such as deprivation of liberty” (Mother of P).  “She is saying repeatedly that she doesn’t want this, but her own lawyer argued in court that she should have it. Surely this can’t be right? She must be entitled to a lawyer who will argue her corner?” (Sister of P).  One family member told me that P was unhappy with her representation and had asked for a change of solicitor, which had been refused.  In addition to these family reports, I have  personally observed several hearings (usually ‘urgent’ ones convened at short notice) at which the Official Solicitor stated explicitly in court that they had not been able to contact P before the hearing and had no direct information as to P’s wishes or feelings.  The role of the litigation friend in this situation seemed largely symbolic. Nonetheless, major decisions (including serious medical treatment) were made at some of these hearings. I raise these concerns here since it seems probable that members of the public may expect this matter to be covered in the Guidance (albeit that I recognise that it raises very different concerns).

Celia Kitzinger


[1] Some of the case law comes from cases concerning children, but Sir James Munby P in RC v CC [2013] EWHC (COP) 1424 (‘C v C‘) confirmed that the well-established (albeit exceptional) jurisdiction to refuse disclosure of materials to the parties in children cases is of equal application in the Court of Protection (at §20). Additionally, some of the Family cases concern adults without capacity predating implementation of the Mental Capacity Act  2005 (e.g. B Borough Council v S & Anor | [2006] EWHC 2584 (Fam).  In the Family Division: In re S (A Child) (Family Division: Without Notice Orders) [2001] 1 WLR 211, Munby J; W v H (Family Division: Without Notice Orders) [2001] 1 All ER 300, Munby J.  In the Court of Protection: Hull City Council v A & Ors [2021] EWCOP 60, KK v Leeds City Council [2020] EWCOP 64.  In the Court of Appeal (concerning a COP case): In the Matter of P (Discharge of Party) AA [2021] EWCA Civ 512

[2] That hearing was ‘ineffective’ (i.e. did not actually go ahead as planned, although it took up more than two hours of court time), ostensibly because the Local Authority had failed to visit the mother’s house to assess the viability of a return home.  (See Claire Martin’s account of this hearing: Medical treatment, undue influence and delayed puberty: A baffling case.)

[3] Litz BT, Stein N, Delaney E, Lebowitz L, Nash WP, Silva C, Maguen S. Moral injury and moral repair in war veterans: a preliminary model and intervention strategy. Clin Psychol Rev. 2009 Dec;29(8):695-706. doi: 10.1016/j.cpr.2009.07.003. Epub 2009 Jul 29. PMID: 19683376.

[4] This concerned a ‘without notice’ application to deprive a vulnerable adult of his liberty under the inherent jurisdiction rather than the Court of Protection. The judge (Mostyn J) did not make any enquiries as to whether the appellant or his solicitor could be contacted in order to make representation. The appeal was allowed and Lord Justice Baker (with whom the other two judges agreed) ruled that “In my judgment, the Trust’s application for, and the granting of, the order for which there was no proper evidence and without giving Mr Mazhar the opportunity to be heard amounts to a clear breach of his article 6 rights and was a flagrant denial of justice.” Mazhar v. Birmingham Community Healthcare NHS Foundation Trust & Ors. [2020] EWCA Civ 1377.

[5] Hayden J, quoted in Joshua Rozenberg’s blog post, “Open Justice at the Court of Protection”, 25th October 2022.

[6] My request to observe that hearing was not motivated by my knowledge of the issues before the court – I’d simply selected a random hearing at a convenient time, and received a reply telling me “The Judge has now been is touch and has stated that you will not be able to join the hearing due to highly sensitive nature of the material being considered.” (email from listings clerk at Leeds County Court).  

[7] I don’t have much confidence in this statistic since (a) there may be other hearings I attended at which judges did not reveal the existence of previous closed hearings; (b) some of the hearings to which I was refused access may have been closed hearings, the existence of which has not subsequently come to light through published judgments; (c) Many of the hearings to which I was not admitted were vacated, so shouldn’t really be included in the total (d) It seems that some closed hearings aren’t ever listed, so I could never stumble over them in making random observation requests. All these factors work in the same direction – to increase the number and percentage of closed hearings in the Court of Protection to something rather higher than my 0.4% estimate.

[8] I found it quite painful to watch this lawyer step out of his advocacy role for A’s mother (she was not at that point raising concerns about the closed hearings) to speak on his own behalf about his experience of the proceedings as Kafka-esque, and about not having been able to advocate effectively for his client. I hope his concerns were managed better outside court than they were during the course of the hearing (where he was simply dismissed as ‘grandstanding’ and corrected for using the word ‘mislead’ – it all felt quite brutal).

[9] Tuckett, A.G., 2012. The experience of lying in dementia care: A qualitative study. Nursing Ethics19(1), pp.7-20.  Elvish R, James I, Milne D. Lying in dementia care: an example of a culture that deceives in people’s best interests. Aging Ment Health. 2010 Apr;14(3):255-62. doi: 10.1080/13607861003587610. PMID: 7140,E., 2009. Withholding truth from patients. Nursing Standard23(48). McCabe, M.S., Wood, W.A. and Goldberg, R.M., 2010. When the family requests withholding the diagnosis: who owns the truth?. Journal of Oncology Practice6(2), p.94. Sarafis, P., Tsounis, A., Malliarou, M. and Lahana, E., 2014. Disclosing the truth: a dilemma between instilling hope and respecting patient autonomy in everyday clinical practice. Global journal of health science6(2), p.128.

[10] https://ugc.futurelearn.com/uploads/files/57/ec/57ecfe86-1a98-4540-b009-bb73660e0883/Guidelines_on_therapeutic_lying.pdf

[11] Bernard Williams, ‘Conflicts of Values’, Moral Luck: Philosophical Papers 1973–1980 (Cambridge University Press 1981.

[12] https://en.wikipedia.org/wiki/Trolley_problem

[13] For applications of the concept of ‘moral remainders’ to legal practice see: Iris van Domselaar (2022) Law’s regret: on moral remainders, (in)commensurability and a virtue-ethical approach to legal decision-making, Jurisprudence, 13:2, 220-239, DOI: 10.1080/20403313.2021.2014709. and van Domselaar, Iris, The Fragility of Legal Ethics: On the Role of Theory, Lawyerly Virtues, and Moral Remainders in the Life of a Good Lawyer (October 27, 2022). Available at SSRN: https://ssrn.com/abstract=4260601 or http://dx.doi.org/10.2139/ssrn.4260601. The concept is also used in theorizing about public policy e.g. Arguelles A & McCaskill J (2018) Minimizing the moral remainder, Journal of Public Administration and Governance 8(3): ISSN 2161-7104.

[14] See How being watched changes how justice is done: ‘Insider’ Perspectives

No ‘exit plan’: Re A (Covert medication: Closed Proceedings) [2022] EWCOP 44

By Celia Kitzinger, 17 November 2022

This was a thoroughly dispiriting hearing to watch.

It was difficult to detect much concrete progress, despite clear directions from the judge at the previous two hearings.

The case concerns a woman in her early twenties (A) who is deprived of her liberty in a residential placement (against her wishes and those of her mother) and has been refusing treatment for primary ovarian failure. 

Every day for two years she’s been offered the prescribed hormone treatment tablet and every day so far, she has declined to take it. That’s more than 700 treatment refusals. Each day, she is then given the tablet covertly via her food.  This course of action was authorised in a ‘closed’ hearing (from which her mother was excluded) before circuit judge HHJ Moir back in September 2020.

Covert medication has been successful in bringing about puberty (and that can’t be reversed).  But medical expert, Dr X, recommends ‘maintenance’ medication for the rest of A’s life – to avert risks of fractures and cardio-vascular events. This is the treatment she’s now receiving (also covertly).

Mr Justice Poole first heard the case at a closed hearing on 15th September 2022, which I didn’t attend, and the existence of which was deliberately concealed from the Open Justice Court of Protection Project. He then heard it again at an open hearing on 20th-22nd September 2022, which three observers attended, resulting in two blog posts: “I have to tell you something which may well come as a shock”, says Court of Protection judge  and Reflections on open justice and transparency in the light of Re A (Covert Medication: Closed Proceedings) [2022] EWCOP 44). The judgments for the two September hearings are published jointly as: Re A (Covert Medication: Closed Proceedings) [2022] EWCOP 44 

In his judgment, Poole J said that covert medication was “unsustainable in the long run”.  He directed that:

 “… a treatment plan should be devised, for review by the court, for how to exit the covert medication regime with the least possible harm being caused to A. The plan will cover the question of imparting information to A about the past use of covert medication – should that be done and if so, when, where and by whom….” (§48(iv) Judgment Part A, 15 September 2022)

The Judge explained his concerns with continued covert medication like this: 

On the one hand, covert administration of hormone treatment appears to be the only way in which such treatment, which it is in A’s best interests for her to receive, can be given. She continues to refuse the treatment when offered to her. On the other hand, the continued implementation of the covert medication plan is fraught with risk. My concerns are (i) that A will discover the fact that she has been and/or continues to be medicated covertly; and (ii) that the discovery will have harmful repercussions in that she will lose trust in those caring for and treating her, perhaps even to the extent of losing trust in all professional carers and healthcare professionals, refusing food prepared for her at her current or other residential homes, and suffering physical and mental harm as a consequence.” (§29 Judgment)

Poole J laid out detailed directions as to the work that needed to be done by way of consideration of the ‘exit plan’ in preparation for today’s hearing.

A medication plan should be drawn up by the Local Authority and the Trust, having liaised with [A’s mother], to address:

a) The transition to open medication with A’s consent and how that can be most effectively and safely achieved.

b) The imparting of information to A about her pubertal development.

c) The imparting of information to A about the risks and benefits of maintenance hormone treatment.

d) The imparting of information to A about the use of covert medication.

The plan will include consideration of whether, when, where and by whom any such information should be given to A, and the involvement of [A’s mother] in the implementation of the plan …. By directing that the issues set out above should be addressed I am not, at this stage, directing what the contents of the plan should be.

….  I shall review the plan and hear and consider further directions on 15 November 2022…

Re A (Covert medication: Closed Proceedings) [2022] EWCOP 44, §63(iii) + (iv)

So, my expectation for the hearing was that a Medication Plan would be put forward dealing with these issues outlined by the Judge and that there would be a productive and sustained focus on how A’s best interests in relation to medication could best be managed going forward.

That didn’t happen.

I haven’t seen the plan presented to the court, but according to the position statement of A’s mother, it was initially of very “limited scope”.  It proposed only:

 “… continuing to covertly medicate A for a further six months unless a new nurse could convince A to take her medication voluntarily.  [A’s mother] had expected it to address fundamental issues such as when and how to tell A that she was now a woman and no longer required the endocrine medication, that the new medication was for a different purpose and what to say to A if the issue of covert medication arose”. (§5, Position statement for A’s mother).

I got the impression that some more work had been done on the plan since 13th November 2022 (the date of the position statement), but clearly not enough to meet the judge’s expectations. 

The Judge expressed ”some regret that more detailed planning in relation to … imparting of information to A about her pubertal development, and contingency planning in event of questions from A…. has not already been done”. 

A miasma of discontent pervaded the proceedings. 

It seemed to me as though all the parties felt backed into a corner by intractable difficulties not of their own making – and various attributions were made (more or less explicitly) regarding the contributions of other parties to the troubles they faced.

The hearing on 14th November 2022

The hearing was supposed to start at 10.30 but was delayed for nearly two hours. We were told first that there had been “traffic problems” and then that the parties were “having productive talks” and the judge had allowed them time for that.   

It was finally called on at 12.24pm, by which time the advocates had managed to produce a (largely agreed) draft order and sent it through to the judge.

The main area of dispute was whether the case should come back for review in 6 months’ time (the position of the Local Authority) or in 3 months’ time (the mother’s position).  

The Local Authority said the Trust agreed with their own position (6 months) but the Trust said it actually didn’t (maintaining a position that somewhere between 3 and 6 months would be appropriate).  The Official Solicitor was initially said, by the Local Authority, to support the mother’s position (of 3 months), but this was disputed by the Trust – and then the Official Solicitor produced a version of their postion that was distinct both from the mother’s position, and from the Trust’s version of the OS position.  It was that sort of hearing – none of the parties seemed content with the characterisation of their position volunteered by any of the other parties. 

I’ll present the position of each of the parties in turn, in the order in which they addressed the judge.

Local authority

Counsel for the applicant local authority, Jodie James-Stadden of Dere Street Barristers began with a long and very granular account of what had been done in an effort to produce a Treatment Plan – the main purpose of which seemed to be to highlight the non-involvement of A’s mother.  

There was “no input received” from A’s mother before the multi-disciplinary team [MDT] meeting on 18th October 2022, despite the fact she’d been sent the date and agenda. Following the meeting, a first draft plan was produced and sent to A’s mother on 20th October 2022 – and she didn’t respond to that either.  A final version was produced following input from Dr X and was sent to A’s mother on 26th October, and “again there was no response received”.    

The finalised version was then filed with the court on 2nd November and “no comment was received from [A’s mother] until she filed a witness statement on 11thNovember, last Friday, during the course of the afternoon”.  According to counsel, “that witness statement raised a number of issues including: ‘should A be told she’s achieved puberty?’; ‘should she be told how she’s achieved puberty?’; ‘what should she be told about the maintenance treatment?’; ‘what should be said to A if she questions whether she’s being covertly medicated?’”. 

These all seem very sensible questions to me, and they are in fact questions which I thought had already been raised by the judge.  I deduce, from the fact that A’s mother was raising them after having received the finalised Treatment Plan, that they had somehow – unaccountably! – not been addressed therein.

There had then been an advocates’ meeting late on Friday afternoon, said counsel, at which the mother’s questions had been discussed by legal representatives “at considerable length”.

There’s now a “Part B” to the plan headed “The imparting of information to A regarding risks and benefits of receiving hormone treatment”.  New promotional health materials are to be prepared for A, and a specialist endocrine nurse will visit A, potentially with her mother’s involvement.  “That part of the plan is agreed by [A’s mother]”, said counsel. 

But [A’s mother] still has- I shouldn’t say ‘still’, sorry.  She has issues of complexity with other parts of the plan, and we agree the MDT needs to explore this.”

Counsel ran briefly through issues of contact between A and her family (it seems this is going okay and can be gradually increased), and made clear that A’s mother is not currently pursuing A’s return home.  She also characterised A’s mother as agreeing that continuing covert medication was in A’s best interests,  but counsel for A’s mother corrected that later: “She is neutral on the issue of covert medication. She is not supportive”.

Counsel ended by highlighting the Local Authority position that “the work to be undertaken with A is very complex work… it cannot be rushed because A will not always engage with the plans or the professionals.  Also the fact that the plan as currently proposed involves a change of focus – that there be a new narrative effectively. In the past the focus has been on achieving puberty. Now the plan is that the narrative to A would be focused on maintenance treatment.  So the dynamic of this plan is very different from what’s gone before. It involves liaison with lots of different professionals.  So our position is that 6 months is appropriate time for sufficient work to be undertaken and for evidence to be collated in the form of statements the court is going to need to properly review this.”

The Judge responded: “I understand the position that [A’s mother] didn’t involve herself in discussions at the MDT as had been hoped, but the order that I made previously….  The issues you are setting out are those that ought to have been addressed already, it seems to me….   My complaint is that this could have been addressed by now.”

Well, quite!

A’s mother

Counsel for A’s mother, Mike O’Brien KC, agreed that the key dispute between the parties was the length of time that should be allowed to see if the Local Authority could successfully get A to take her medication voluntarily.  Six months is “much too long”. If it can’t be achieved within 3 months, then A’s mother wants to be fully involved and take the lead.

For A’s mother there’s a crucial distinction between the old medication (to bring about puberty) and the new medication (for maintenance of A’s long-term health now that puberty has been achieved).  She thinks A will understand and appreciate that distinction, and will agree to the current medication on that basis.

But that proposal requires that someone tells A that she’s gone through puberty – and that (for A’s mother) is one of the key shortcomings of the current plan.  

There are no clear proposals to tell A that she is even an adult. This has never been discussed with her. It’s extraordinary that we’ve got to this stage where no one has engaged her in that conversation, and explained to her that the new medication has a different purpose.  The conversations have always been about puberty. [The mother’s] view has always been that A will accept the explanation that the medication is for her bones and her health. What the medication plan also failed to address was what was going to be said to A about how she became an adult, or how questions would be responded to about whether there had been any covert medication. [A’s mother] has not suggested that A needs to be told about the covert medication – that may not arise, but there needs to be contingency planning to deal with it if it does, and there hasn’t been any.”

A’s mother is worried (given past conflicts with professionals) that she would be blamed for any leak of information to A about covert medication or her daughter’s pubertal development.  This makes her especially worried that the Medication Plan sidesteps these issues.

The mother’s counsel also addressed the Local Authority’s characterisation of A’s mother as not having engaged in a consultation about the Medication Plan.  She doesn’t use email.  She wanted to speak to counsel (i.e. him) and he was in Egypt until last Wednesday.  She doesn’t want to attend an MDT meeting “unless she’s got somebody with her. There have been difficulties with relationships in the past. [A’s mother] would feel uncomfortable going into a room full of professionals by herself”.  (As someone who’s been characterised as a ‘difficult family member’, oh yes, I resonate with that!). Later, the judge said he recognised that MDT meetings were “potentially rather intimidating events for [A’s mother] to attend, particularly given the history of the case” and so he was “content to approve expenditure on a solicitor to accompany her,  and for that to be covered by the [legal aid] certificate”.

Finally, it seems that A’s mother has filed an appeal application against HHJ Moir’s decision, made in a closed hearing, to covertly medicate A.  Counsel referred to the Court of Protection Rules Part 13 (“Setting aside or varying default judgment”). There was some discussion about whether this would be heard by a Tier 3 judge (such as Poole J) or by the Court of Appeal, and whether it would actually make any different to A or to her mother.  “We are where we are,” said the Judge, “but it may be of broader interest.”  He also drew attention to the fact that the Court of Protection Rules Committee is considering closed hearings.  In any case, that appeal application was not considered today.

Trust

Counsel for the Trust, Joseph O’Brien KC of St Johns Buildings Barristers’ Chambers said his submissions would be brief (it was nearly 1.30 and the judge had enquired about the need for a lunch break).  He would confine himself to some observations about the Treatment Plan and then address the matter of whether the case should come back for review in 3 months or 6 months or somewhere in between.

 But first he indicated his objection to the version of events concerning the mother as presented by her counsel: “I don’t want and am resistant to responding in detail to some of the submissions that Mr Mike O’Brien has made, by drawing down on past history. I don’t want to do that because I think it’s not absolutely necessary, but some of the narrative before the court is of course not accepted”.  Then he moved on. For anyone interested in rhetoric at the Bar, the device of saying something by stating that you’re not going to be talking about it is a figure of speech known as ‘apophasis’ (e.g. to use a Shakespearean example, “I shall not mention Caesar’s avarice, nor his cunning, nor his morality”. (Donald Trump uses it a lot too. For information about apophasis, see Merriam-Webster on ‘apophasis’; and for a broader look at the language of legal advocacy see: “Advocacy in the William Verden hearing” and “Cross-examining a GP in a COVID-vaccination hearing“.)

Counsel referred in passing to the findings of HHJ Moir’s closed hearing (the one on 25th September 2020, at which she authorised covert medication) and this reminded the judge that there was in fact no transcript, and he said that he would direct that one should be prepared – later adding that he intended that it should be made publicly available via the National Archives.  This is really important (in my view) because at present there is no public record of how the decision to covertly medicate A for such a long period of time, and to withhold that information from her mother, was made. 

After a 30-minute lunch break, counsel returned with two points.  (1) on the issue of A having gone through puberty, “there’s never been a determination by the court that imparting that information is in her best interests”, so – insofar as that matter has not been addressed in the Treatment Plan,  there has been no “rowing back from an order”; and (2) on the issue of when the case should come back for review, he disputed the alignment (previously claimed by counsel for the Local Authority) between A’s mother and the Official Solicitor on the matter of a 3-month return date, pointing out that while counsel for A’s mother “demands a hearing three months almost precisely from today”,  the Official Solicitor wants a full 3-month trial, and then an MDT meeting, after which parties would “pull everything together” and then return to court.  Expert opinion, he said, is that the relevant plan and assessment of it “cannot and should not be done within 3 months”: “In my respectful submission, that is almost magnetic as to where you should go in respect of case management”.

Official Solicitor 

Counsel for A via her litigation friend the Official Solicitor was Sam Karim KC of Gatehouse Chambers. He’s played a relatively low-key role in this case, at least in terms of his contributions in court. He made three observations. 

(1) He supported the continuation of covert medication as necessary, proportionate and justified under these “exceptional” circumstances. 

(2) He said 3 months was the right time scale for running the trial to see whether the Local Authority can persuade A voluntarily to take the medication – and that the case should return to court after a subsequent MDT.

(3) He raised the question about whether an independent expert psychologist or psychiatrist would be of benefit to ascertain whether there are other ways to engage with A. (I don’t think this went anywhere – which is a pity, in my view.)

Judgment

In summary, the Judge accepted that A continues to lack capacity to make her own decisions in the relevant domains (including medication, residence, care, contact).

The Judge authorised continuation of covert medication – pointing out that everyone but her mother considers this to be in her best interests, and that her mother does not oppose it.  He said that A had taken an “intransigent position” on medication, and that her opposition is rooted in a lack of trust of professionals “borne from her relationship with her mother. It is illogical and doesn’t have a rational basis”.  Covert medication is an exceptional course to take but it will bring A significant benefits with negligible (if any) risks.

Discovering, in an unplanned way, that she has been treated without her knowledge and after explicitly refusing treatment could, said the judge, be harmful to her, and the longer covert medication continues, the longer that risk continues.

The judge set out three options: (1) Continue covert medication for the forseeble future; (2) Make the transition to overt medication; and (3) Cessation of treatment. “There may be circumstances in which cessation might be in A’s best interests, especially compared with covert medication, but the second option is the preferred target: to end covert medication on the basis that she voluntarily accepts it.”

The Judge expressed ”some regret that more detailed planning in relation to … imparting of information to A about her pubertal development, and contingency planning in event of questions from A…. has not already been done”. 

He will list the next hearing for a date in mid-March 2023 – probably as remote hearing, since he’ll be in Leeds hearing a long case then. The court will then “review the updated medication plan, its implementation, issues of contact and whether there’s a need for any directions in relation to the residence application”

In the meantime: 

I am concerned about contingency planning in the event – that could happen at any time – that A raises questions about her own pubertal development. It seems to me this ought to be addressed as soon as possible. I urge those who are caring for and treating A to address their minds as soon as possible to what responses would be given were A to ask the sorts of questions we’re been discussing: “why have I changed?”; “why have I developed breasts;  “have I been given treatment I didn’t know about”. I’d hoped that would be in place by now.” (Mr Justice Poole)

Concluding observations

This was an uncharacteristically lack-lustre hearing.

From my perspective as an observer, there was a rather sullen, sour, and fractious tone to the proceedings, which contrasts with the collaborative (‘inquisitorial’) commitment to P’s best interests which I usually see in the Court of Protection.  The Judge – always courteous and rather more patient than I might have been in his position – had to do a lot of the ‘heavy lifting’ throughout this hearing.

The stultifying lack of progress is really worrying – not least because the Local Authority and the Trust have had years to prepare for this. 

At any point in the last two years of treatment, A might have discovered the medication in her food, or been alerted to the medication by a carer.  At any point her grandparents (who visited her in person) could have commented on her pubertal development and raised suspicions.  Or she herself could have questioned her breast development, her hair growth or changing body shape. Was there really no contingency plan in place to deal with this?   It’s extraordinary to me that the deception has lasted so long, and apparently so effectively (if it has).  Or perhaps – as sometimes happens in other fraught and difficult situations (when a loved one is dying, for example) –  A is simply colluding with the conspiracy of silence in which she’s enmeshed: at some level “knowing” and at another level avoiding knowing what’s been going on.

When the closed proceedings before HHJ Moir are finally made public, it should be possible to understand how the court had intended this should all be managed, and how it might end. 

It’s hard to believe that there was no planning for the possibility that A might uncover the covert medication or that a shift to voluntary medication might not have been envisaged at some future point.  And yet, from the difficulties the Local Authority and the Trust seem to be experiencing with the judicial direction to address these contingencies, it comes across as if this kind of advance planning for an ‘exit strategy’ from covert medication is a wholly new idea.

I look forward to seeing how things have developed for A by the next hearing – and hope for a more engaged and collaborative approach from the parties to addressing her best interests.

Celia Kitzinger is co-director (with Gill Loomes-Quinn) of the Open Justice Court of Protection Project.  She tweets @kitzingercelia

Note: We are not allowed to audio-record hearings. All material quoted from the hearing is as accurate as I can make it, based on contemporaneous touch-typed notes, but it is unlikely to be 100% verbatim.

When wishes and feelings change: A s.21A case but the applicant is now happy with where she lives

By Joanna Booth, 16 November 2022

The case I observed on 10 November 2022 (COP 13966522) was heard before Deputy District Judge Sophy Miles.

A woman, SB, is in a care home waiting for dementia and occupational therapy assessment. Her age was not mentioned. 

She’s been deprived of her liberty since 27 February 2020. 

When first visited by a social worker, P was raising concerns about the location of her placement. The details of the concerns were not mentioned at the hearing, but they had led to a s.21A application.

A request had been made by SB’s brother and sister-in-law to have her moved closer to them. They had identified a care home, which they were familiar with and had friends there. It was within walking distance from their home. 

A roundtable meeting was meant to have taken place between the parties before the hearing, but it didn’t happen because of problems on the side of the respondent local authority. The person dealing with the case was on leave. The original solicitor for the respondent had been ill and a replacement had stepped in at the last minute. The local authority had also not provided a position statement for this hearing

By the time of the social worker’s second visit,  on 29th September 2022, to assess SB’s wishes and feelings, SB’s views had changed. 

When the social care worker arrived, SB was sitting in her wheelchair, wearing leggings, a pink top and a cardigan. She commented on the social care worker’s attire that it was a horrible colour.

According to the attendance note report:

SB understood that the social care worker was there to help her and decide on her future. She wanted to stay at the care home she was in. She liked the staff. She said about her brother and sister-in-law, “I don’t want to be tiresome to them. [Brother] calls me all the time. If I moved close to them, they’d feel as if they had to visit all the time. The staff are lovely to me. Why would I want to leave? 

Her room was clean. Her brother and sister-in-law hadn’t visited but they called all the time.

Apparently, her legs and arms were getting worse. We weren’t told what condition she was in physically at all. But she said that she needed more PIP and an electric wheelchair. 

She could do art, which she really loved.

The judge asked if the attendance note was in the bundle. It was not but was being placed there during the hearing. 

Neither SB nor her family members were present at the hearing. No witness statement had yet been sent in by SB’s family. 

The judge noted that the matter had been brought appropriately before the court but the situation seems to have changed since SB now seems to want to stay where she is. The brother and sister-in-law said they had a care home within walking distance and were familiar with it because they already visited friends there.

The judge directed that the family members be asked to consider how visits to SB might conflict with their schedules.

SB’s desires had apparently changed. From what I understood, she had originally wanted to be moved but now she doesn’t anymore. 

Orders by the judge

The judge made the following orders and  directions at this hearing:

  • A transparency order protecting SB’s identity in the standard terms.  (I have subsequently received it, after chasing!)
  • A roundtable meeting to take place in the week beginning January 9th 2023. Hopefully with SB in attendance.
  • The relevant NHS trust had not yet provided the report it was supposed to under s.49 MCA (see, “What is a Section 49 report”). They weren’t even sure yet as to who was meant to provide it, apparently. An order was made for this to be provided later in December.
  • Two updates on referrals had yet to be fulfilled: 1) referral for a brain scan for dementia; 2) referral to occupational therapy, which was particularly important considering what SB had said about her arms and legs getting worse. 
  • A report on the availability of care homes near SB’s brother; and the activities each care home provides since SB had said she loved doing art at her current care home. 

The next hearing is listed for 30 January 2023 at 10.30 am.

Joanna Booth is a freelance journalist who writes at joannab.substack.com. She studied law, politics, and social research methods, and worked for years as a social researcher in higher education organisations. She now works as a journalist, and is working towards a PhD by publication on local media and political participation. She tweets @stillawake

Application to name a protected party in the context of ‘jigsaw identification’

By Brian Farmer and Celia Kitzinger, 3rd November 2022

Very occasionally, the person at the centre of Court of Protection cases is publicly named in judgments and in the media.  Recent examples include  William VerdenRobert Bourn, and Michelle Davies.

This is unusual. the default position in the Court of Protection is that the protected party is referred to as “P”, or by initials like “SN”, “RT”, ‘AB” etc, so that their identity is not public knowledge.  

Reasons for naming someone depend on the individual circumstances of each case. Sometimes it’s because the person wants (or would have wanted) to be publicly named, because they’re a political figure and a campaigner (e.g. Manuela Sykes). Others are reported by their families to want to help others by having their experience shared in the media – like Robert Bourn and Michelle Davies, both of whose stories have appeared on national television. Sometimes they are publicly named in order to draw attention to their own situation and get help – like Steven Neary, whose father Mark Neary turned to the media out of desperation to get support and guidance. For William Verden, naming him was in order to maximise the chance that someone would donate him a kidney.

This is about a case where (although the family, and it is said the protected party herself, also wanted her name to be used) the application to name her focused on the problem of “jigsaw identification”. Basically, this refers to a problem that arises in reporting cases where the salient facts are such that a meaningful report is likely to enable readers to identify the person at the centre of the case, even without naming them.

Introduction by Celia Kitzinger

Brian Farmer, the only journalist regularly to observe Court of Protection hearings, was in court (as was I) to observe a case before Mr Justice Cobb on 18th August 2022.

It concerned a woman in her 30s with autism and what was described as “a hugely complicated medical background”. She was in hospital on a High Dependency ward, intubated and mechanically ventilated.  There were disputes about her treatment (although it wasn’t clear quite what those were) and there was an “extremely difficult relationship” between the Health Board and her parents.

Her parents were in court as litigants in person (i.e. without lawyers to represent them).  Both were medically trained. Her father had been a consultant anaesthetist in the very hospital where his daughter was now a patient.  Her mother was an ICU nurse.

I have blogged about this case previously: “I am fearful for my daughter’s life”: Serious medical treatment in a contentious case“.

This blog is not about the substantive issues concerning treatment but about the right of observers (me and Brian Farmer) to report on the hearing, and to ensure the public know about it.

In order for that to be possible, Brian Farmer applied to the judge to “vary the transparency order”. 

What is meant by “varying a transparency order”?

A “transparency order” is an injunction that is supposed to be served on everyone who attends a public hearing in the Court of Protection.  

It’s a court order which says, at the beginning: “If any person disobeys the order … they may be found guilty of contempt of court and may be sent to prison, fined or have their assets seized. They have the right to ask the court to vary or discharge the order”.

The ‘standard’ transparency order is made to protect the privacy of the person at the centre of the case.  Although their name and the names of their family members are usually used publicly in court, it’s very rare that anyone is allowed to report them.  Usually,  we can write about the case, explain the issues before the court, and quote what was said – so long as we don’t say or write anything “that identifies or is likely to identify” the person at the centre of the proceedings or their family (and, often, nothing likely to identify the carers either).  

Here’s what the relevant paragraph of the injunction says about the information we’re not allowed to communicate.   (The whole order consists of 17 paragraphs plus an Annex, over seven pages of legal language.)

from the Transparency Order we were sent for this hearing

So, we’re not allowed to report that LW (the woman at the centre of the case) is involved in a Court of Protection case (that’s 6(i)(a)).  

Nor are we allowed to say anything likely to identify her family members (“CW” and “EW” are her parents) (that’s 6(i)(b)); or her care team (6(i)(c)).  

And 6(ii) prevents reporting anything likely to identify where any of those people lives, is being cared for, or their contact details.

This is the sort of order that we see a lot in the Court of Protection.

 It’s designed to support transparency and open justice in the Court of Protection (the public’s Article 10 rights to freedom of information and the long-standing commitment to justice not only being done, but being seen to be done) while at the same time protecting the privacy (Article 8 rights) of the person at the centre of the case and their family.

With that Transparency Order still in place, Brian Farmer was able to publish this account of the case: “Retired nurse tells judge her daughter ‘is not safe’ in hospital”.

Jigsaw identification

Sometimes, though, there are problems with the standard Transparency Order that make it impossible to report meaningfully on a case without conveying information that makes it “likely” that the person at the centre of the case can be identified.

Occasionally the person at the centre of the case is so famous (e.g. as a politician, a sportsperson, a media celebrity) that almost anything you write about the person risks identifying them, because so many facts about them are already in the public domain.  

That wasn’t so in this case, but “LW” (who was now unable to communicate her own views about being identified or not) had spoken to the media before, and campaigned to raise money for people with her rare disease (Ehlers-Danlos syndrome), e.g. Rotherham woman with rare condition steps up ‘life changing’ surgery campaignWoman who dislocates her shoulder every night says Nottingham doctors ‘saved her life’.

The wording of the injunction (“identifies or is likely to identify”) means it’s not just naming someone that is prohibited – it’s reporting information on the basis of which someone could figure out who the person is.  

So, if Brian and I reported that LW had Ehlers-Danlos syndrome and autism, that she was in hospital and that her parents (one of them a consultant in the hospital where his daughter was being treated, the other a nurse) were critical of the treatment she was receiving, this could provide sufficient information to identify who she was.  

In the ‘anonymised’ article Brian published on 18th August 2022, he did not describe the father’s job, but only said he had “a medical background”. 

Concern about “jigsaw identification” (i.e. little bits of information which can be pieced together to identify someone) often leads to specific and peculiar prohibitions being included in Transparency Orders (e.g. P’s nationality, their diagnosis, the number of children they have)[1].  Most of the time, though, we have to figure out for ourselves what pieces of information might be covered by the Transparency Order, and that’s one of the challenges of trying to comply with it.  

The potential for jigsaw identification, by which is meant diverse pieces of information in the public domain, which when pieced together reveal the identity of an individual, can sometimes be too loosely asserted and the risk overstated. [J]igsaws come with varying complexities. A 500-piece puzzle of Schloss Neuschwanstein is a very different proposition to a 12-piece puzzle of Peppa Pig.  By this I mean that while some information in the public domain may be pieced together by those determined to do so, the risk may be relatively remote”  (Hayden J, at §18 A Local Authority v A Mother [2020] EWHC 1162 [FAM]). 

It can be challenging for us to figure out how risky it is to report certain facts, or how likely it is that they might result in identification of P.  In practice, this often leads me to self-censor.

Where relevant details would very likely lead to identification of P, it can sometimes make more sense to simply apply to name P.

Public interest and P’s own views

There was public interest in writing about this case in part because the Health Board that the parents were criticising (Betsi Cadawaladr) had recently been criticised in a completely unrelated case in the Court of Protection, before a different judge.

The parents – who were also bound by the Transparency Order – were distressed by it because they wanted to post about their daughter on Facebook.  “We have friends all over the world. We are active Christians.  We want to be able to make clear posts about what is happening to our daughter, with requests that prayers are offered for her recovery.  Facebook is the way we keep people up to date and get prayer cover.”  (This would not in fact be captured by the Transparency Order unless they also said that a court was making decisions about their daughter – but I thought it unlikely that they would want to omit that information, and in fact I can see from Facebook several references to the court case.)

It also seemed that LW wouldn’t have minded people knowing her identity – and might even (as her parents said) have wanted her identity made public.  She had approached the media to tell her story publicly before, and chosen, when she had capacity to do so, to be photographed for the press.  Her mother referred to the court as “stealing her [daughter’s] identity” by making the Transparency Order.

Presumably because of the parents’ view that LW would have wanted her identity to be known, the judge said that the Transparency Order was an ‘interim’ one and would be reviewed at the next hearing.  The judge invited submissions and Brian Farmer submitted the letter reproduced below.

In applying to vary a Transparency Order, the key arguments applied to the facts specific to each case concern the likelihood of identification of P, P’s own likely views and best intersts,  and the balance between the right to privacy (Article 8) and the right to freedom of expression (Article 10).  

We have published letters seeking variations in Transparency Orders several times previously[1].  The letter from Brian Farmer reproduced here is helpful because any of us may in future want to challenge reporting restrictions and his arguments are ones we can all learn from.

Letter from Brian Farmer to Mr Justice Francis seeking to name the protected party

Dear Judge,

I was at the hearing before Cobb J on August 18 and wanted to ask if you would consider relaxing the transparency order and allowing P to be named in media reports of the case.

I appreciate this is an unusual application.

This isn’t a case where P is easily identifiable because she is well known.

The problem here is simply that the circumstances of the case – specifically the occupations of P’s parents – make it very difficult to write a meaningful report without creating jigsaw identification.

I don’t think it’s just a problem for reporters: I suspect a judge will also have difficulty producing a public judgment.

I’d make the following points:

1: Hearings are being staged in public.

2: The case raises matters of public interest –

(a)  You are being asked to make decisions about serious medical treatment.

(b)  The health board was criticised by Mr Justice Hayden in October (Re. PH) “North Wales health board’s ‘substantial and alarming failures’ in care of man slammed by top judge”

(c)   P’s parents made serious criticisms of P’s treatment at a hospital run by the trust during the August 18 hearing (particularly mother).

(d)   P’s parents’ criticisms carry extra weight because father is a consultant employed by the trust and mother is a retired senior nurse.

3: Lots of material relating to P and her health is already in the public domain – in media reports and on social media. Detail was outlined in Ms Sutton’s position statement prepared for the August 18 hearing. That information would seem to suggest that P would not object to details of her health being made public if she had capacity.

4: P’s Article 8 rights are obviously engaged. I would not normally argue that a CoP P should be identified and detail about health conditions made public.

5: However, I would argue that in this case there’s a public interest in reporting the parents’ criticisms and telling people what their jobs are or were – particularly in the light of Hayden J’s criticism. I can’t see how to do that anonymously: giving detail of the parents’ jobs will create an obvious risk of jigsaw identification. How many other patients have parents with those jobs?

6:  Given the amount of information in the public domain about P’s health, what harm would naming P cause? We’d essentially only be telling people that P has another health problem and is a patient in a CoP hearing.

7: I’m not clear what position P’s parents take in relation to P’s identification. They said, on August 18, that P would want her real initials used on documents. Using P’s real initials would obviously add to risk of jigsaw identification.

8: There’s also an issue in relation to what’s already in the public domain. We can’t tell people what’s already in the public domain about P without breaching the transparency order. I’d argue that we should be able to tell people what’s already in the public domain.

Brian

Outcome

The judge gave permission to name LW as Laura Wareham, and to name her parents as Conrad Wareham and Erica Wareham.

This meant that Brian was now able to publish the information that the patient’s father, Conrad Wareham was a consultant and “a specialist in the care of critically ill patients” (see: Judge criticises consultant concerned about how doctors are treating his daughter at Welsh health board“).  It meant he was able to address the sensitive issue of how a family member with (substantial) medical knowledge engages with the medical treatment of his daughter.

It also means that Conrad and Erica Wareham can write publicly on Facebook (and elsewhere) and speak to the media about the role of the Court of Protection in their daughter’s life (although they are not allowed to name the hospital where she is being treated, or the people involved in her care).  

Celia Kitzinger is co-director (with Gill Loomes-Quinn) of the Open Justice Court of Protection Project. She tweets @kitzingercelia

Brian Farmer is a reporter with the PA news agency.


[1] For examples of variations to Transparency Orders related to issues other than naming P, see:

Improving P’s quality of life pending a s.21A change in residence

By Celia Kitzinger, 28th October 2022

The person at the centre of the case (I’ll call him “Peter”) is a 71-year-old man who is held against his will in a care home that is not meeting his needs.  

It’s a Section 21A deprivation of liberty case (COP 13825795) before Her Honour Judge Buckingham, sitting (remotely) on 20th October 2022.

Peter was in court throughout.  He is “deeply unhappy”.  He conveyed his distress and frustration very articulately

Before moving to the care home,  Peter lived in a guesthouse by the sea, with support from a personal assistant, the (clearly wonderful) “Jennie”, described by the Official Solicitor as “a positive supportive influence to which [Peter] responded positively and willingly”. 

Apparently, the previous placement broke down for reasons associated with his alcohol consumption, which is why he is now in the care home.

A psychiatrist assessed Peter and reported that he had severe cognitive impairment as a result of alcohol damage and in February 2022,  the judge made declarations that Peter lacks capacity to conduct these proceedings, and to decide where he lives or what care he receives.  So he’s now deprived of his liberty in accordance with a Standard Authorisation.

But Peter hates the care home.

Since he’s been there his alcohol consumption has increased and from what I heard it sounds as though there’s been virtually no support available to him with managing his alcohol habit. He’s also smoking 20-40 cigarettes a day, which means nearly £200 every week spent on cigarettes and alcohol.

He is increasingly desperate to leave the care home and to return to the seaside town where he lived before.

There was a litany of complaints and concerns about his current placement, raised both by P in person and by the Official Solicitor on his behalf – all of which the judge took very seriously. They include:

  • Peter is not allowed to go out (or “access the community” in DOLS-speak) as often as he would like. His son suggests he’d enjoy museums, art galleries and the cinema, as well as the park, shops and sauna that he is occasionally able to visit. 
  • He doesn’t get the opportunity to exercise (“a rabbit in a cage gets more exercise than I do”).  He says he wants to go for brisk walks in the fresh air, do some jogging and swimming.
  • In part his lack of access to the community is because he’s assessed as needing 2:1 support – which causes practical problems due to staff availability and is tied up with funding issues.  (Peter tells the judge, “I have to ask permission to go across the road and it’s always ‘oh we’re too busy’ or ‘we’re short-staffed today’”).
  • So, Peter is confined to the care home for much of the time and there’s nothing much for him to do there.  Asked by the judge about what activities the care home offers, the social worker volunteers only cooking and baking, watching TV and a garden area to sit out in. As the judge says, “not a wide range”.
  • He’s lonely and bored. “Why take Jennie away from me and give me school-leavers, which some of these people are, who are only interested in watching Coronation Street and talking about their last boyfriend? They don’t give tuppance about me or anyone else in that building”, says Peter.
  • There’s some dispute as to whether or not Peter is receiving the alcohol allowance authorised by the judge, and how it is paid for.
  • Peter says items have gone missing from his room: expensive trainers, pinstripe suits, a watch (“even toothbrushes, would you believe!”).
  • Nobody will support him to go to the bank to withdraw money (he has a private pension), but without access to his account, “I’m penniless. I can’t even buy a bar of chocolate”.
  • There’s no chair in his room: According to the position statement by the Official Solicitor, “The Care Home refused to provide this stating it was not standard issue and they would not be able to provide one. The [LA] therefore confirmed they would pay for a chair however one has still not been provided”.

Peter uses the language of incarceration (his room is a “cell”; other residents are “inmates”) to underscore how strongly he feels about his deprivation of liberty. 

He asked the judge:  “What am I being charged with and what is the allegation because I’ve not been told.  I’m on an open-ended sentence. I’m now into 12 months and it’s still an open-ended situation and I haven’t been charged with anything.” 

The judge explained:  “As I said last time, this is not a criminal court. I’m not a criminal judge and you are not facing any criminal allegations.  I know it feels like prison to you, but you are not at your current placement because of any criminal charges. […]. I know it feels like a prison to you, and you’ve told me how despondent you are.”

The plan, as the judge explained to Peter, is to investigate whether and how he might be able to return to the town where he lived before, with an appropriate package of support. 

The judge was hopeful that this could include Jennie (and her partner Tony) as “Shared Lives” carers. Assuming it works out, there’s a 2-3 month checking process and some training before Jennie and her partner can become Shared Lives Carers.

At the hearing I watched, the lawyers were: Jill McCurdy of Ramsdens Solicitors, representing Peter (via the Official Solicitor); Simon Batt (the in-house solicitor representing the City Council, the first respondent); and Barbara Green of Spire Barristers representing the County Council, the second respondent). Peter’s social worker was also in court.  

Peter’s son and daughter, the third and fourth respondents, support his wish to move out of the care home. The son was present and spoke on behalf of both of them.

I’m not sure why Jennie wasn’t in court – or whether she’d been offered the opportunity to be present.  Given her past relationship with Peter as his personal assistant, and her possible future relationship as his Shared Lives carer, her involvement in court might have helped with sorting out the miscommunication and disputed facts of the case. 

The judge patiently worked through all the concerns, trying to untangle what the problems were on the ground and work out how to ensure things moved forward more smoothly. 

The hearing took nearly three hours – in part because a fire alarm went off in one of the advocates’ buildings, which meant the hearing was forced to adjourn for about half an hour. It continued until 4.50pm, with the judge reassuring Peter at one point that she had “plenty of time” to hear him out.

Supporting Jennie’s involvement with Peter

Let’s start with the positives”, said the judge, turning to the fact that the assessment process for Jennie and Tony had begun.  She wanted to know if the organisation assessing them had experience “in assessing people for supporting those with a chronic alcohol habit” and emphasised that Jennie and Tony would need external support.  It shouldn’t be allowed to fail for lack of external support.

Pending the completion of the assessment and possible move, Jennie is willing to visit Peter on a weekly basis for four hours, subject to funding being agreed for her to make such visits on an hourly personal assistant rate, together with travel expenses.  The local authority has agreed to fund this. 

The Official Solicitor supports visits from Jennie and Tony:  “such an arrangement would not only enhance [Peter’s] happiness and day to day living arrangements but would also serve to test out the potential placement by contributing to the assessment giving valuable insight into the viability of them as Shared Lives Carers”. (Official Solicitor)

But it emerged that, a few days earlier, Jennie had travelled from her home to the care home (some distance by train) to see Peter, “only to find she wasn’t allowed to go out into the community with him, despite the role she’s played in his life previously. How did that happen?”, asked the judge.

The social worker responded by saying that it hadn’t been agreed that Jennie’s visits to Peter should begin yet: “The discussion we had was about exploring the option, not about it actually being implemented at that moment in time. We have to follow the process.  We have a process.”   

There was disagreement about whether it had, or had not, been agreed, and who had informed whom – and the judge emphasised the importance of “better communication”.

Can that be done quickly,” she added, “because every day that Peter is left feeling, as his son says, ‘aimless and drifting every day’, it’s a vicious spiral in terms of him becoming less receptive to advice.”

There was also some uncertainty about the duration of the visits.  The son said that Jennie and Tony were willing to “spend six or seven hours on a quality day out” with Peter, even if they were only paid for four hours – but the judge made clear that these visits should be limited to  four hours for now “to allow that to bed down”, and the duration would be increased if the visits were successful.

Issues that need to be resolved and understood between everyone include: what time Peter will be collected, how much alcohol he’s already consumed by that point and how much he’s allowed to consume during the visit, how long he will be out of the care home for (a maximum of 4 hours), and what time he will return.

I’m disappointed that hasn’t happened already”, said counsel for Peter via the Official Solicitor.  “It’s what the previous order provided for, for a Contract of Expectations to be prepared.  I would ask [the social worker] to ensure that her communications are clear…. I invite a Contract of Expectations as a document everyone can share, including Peter himself”.

Alcohol consumption

At a previous hearing the judge had authorised alcohol consumption for Peter.  He was to receive 30ml of whisky (with lemonade) at one-hourly intervals, on twelve occasions, from 7am onwards each day – which amounts to between 84 and 90 units of alcohol per week (the recommended maximum is 14 units).

There was some confusion and disagreement about whether or not the local authority was responsible for buying Peter’s whisky.  Peter’s son thought that was so, on the grounds that alcohol was “medically required”. 

The judge explained the current situation to Peter’s son like this: “I was very reluctant to authorise this.  It’s a ticking time bomb to continue to provide alcohol at this level and it’s storing up problems in terms of liver sclerosis, heart disease, stroke etcetera.  But given the costs of care, your father would literally have no money to buy alcohol at all, which would put him at risk of seizures. On that basis I authorised the plan, and it was agreed that the costs of your father having that level of alcohol would be disregarded for the purposes of care. So, the local authority is indirectly funding it.  Their position is ‘we will not provide the funds for it, but we will not enforce our right to take funding from his assets when we would ordinarily be entitled to do so’.”

There has still been “no proper medical information” about Peter’s alcohol use.  The judge said: “A GP appointment hasn’t happened, and I don’t know why. There are mixed accounts of why it hasn’t happened.”  A referral to an organisation that supports people with drug and alcohol issues also hasn’t progressed.

There was also a disagreement about whether in fact Peter was receiving alcohol in accordance with the plan the judge had authorised. The care home says he is.  Jennie and Tony had reported he wasn’t – although their version likely comes from what Peter tells them and is not an independent account.  Peter’s son cited the Care Quality Commission report about the care home  from a couple of years ago and said he was concerned that the care home records are unreliable and inaccurate. Although the son was generally measured in how he spoke, he was very critical of the care home (and the social worker) – and the judge pointed to “a great deal of mistrust here between the family and the care home”. 

Peter’s son suggested that his father should be invited to sign and date the care home records: “it would give them more credibility”. The judge agreed that Peter could be invited (but not required) to participate in the care home records – and also that if there is any disruption in dispensing the alcohol that they should contact the social worker immediately.

There was also some discussion of obtaining an expert report on the matter of Peter’s drinking – and of addressing his back pain because “that means he uses alcohol as a mitigator”. It seemed agreed that “Jennie is the best chance of that engagement being successful”.

Money

The Official Solicitor reported that Peter is “preoccupied with the worry that he is owed money and he does not know where his money is going or how it is being spent. It does not appear that the [Local Authority] or the Care Home are acting in a way consistent with the ethos of the Mental Capacity Act by supporting [Peter] in a way which empowers him to access his own financial arrangements and have as much control as possible in respect of the same.”  It appears, said the Official Solicitor, that Peter’s efforts to engage with his own financial concerns have been “thwarted”. Not being able to access his funds “causes him daily distress and agitation”.

The social worker’s view was that he didn’t need to access his funds:  “I believe he fails to understand and appreciate there is no reason for him to do this given that [the LA] have been appointed as DWP benefit appointee”.  

The Official Solicitor says “this represents a significant misunderstanding of the situation”, since Peter has a private pension in addition to his state pension.

The judge asked how quickly Peter’s bank statements could be made available to him and there was a discussion about mini-statements from a hole in the wall, or bank statements online, and whether paper statements are still available and how to get them.

There was also talk of a capacity assessment for Peter’s ability to manage his own money, and the possibility of appointing his son (and maybe also his daughter) as Finance Deputies.

A chair for Peter’s room

It’s been promised. It’s on order.

Missing Items 

It’s important when someone raises a complaint that even if it is a misunderstanding on their part that it is fully investigated.  When Peter moved in there will be an itinerary of his possessions and it will, or it won’t, include expensive trainers, pinstripe suits and a watch.  And if they were on that list, what has happened to them?” (Judge)

Exercise and activities in and from the current care home

One way of enabling Peter to get out more, go for walks, swim etc is for him to be permitted to go out of the care home with 1:1 staff ratio, rather than the requirement that he has two members of staff with him at all times, as at present.  Another way is to leave the 2:1 in place but for the local authority to increase Peter’s entitlement to staff time.

Judge:  What power do I have if the care home say they are not prepared to let their staff go out one-to-one?

Counsel for the LA: The court has no jurisdiction.

Judge: So I could say 2:1 is not proportionate or necessary but then the care home would give notice.

Counsel for the LA: That’s the reality.

Judge: And then they’d say ‘good luck to you, if we give notice, finding somewhere else’!

Having explored the activities available to Peter inside the care home the judge said: “There aren’t many opportunities available for him here – cooking, baking, sitting in the garden, watching TV. There’s not much mileage in it.  It’s very much to Peter’s credit that he wants to exercise, when the rest of us are all encouraged to exercise more than we do.  It must be a priority. … Are there Personal Trainers who work with elderly people with cognitive impairments?”  Nobody seemed sure. 

Counsel for the LA suggested looking for alternative placements other than in the coastal area to which Peter wants to move.  But the judge wanted something done now. She asked the LA to “think urgently and laterally about how [Peter’s] circumstances can be improved.”

A new placement

The search for a new placement is ongoing

Peter:  If it ran smoothly and to course, what time scale are we looking at?  I’ve served 12 months now […] I’m working my time now. I could have put a brick through a shop window and I’d be home by now.”

The next hearing is in April 2023.

Reflections

Until I started watching Court of Protection hearings two-and-a-half years ago, I had no idea that hearings like this happened.  But they’re quite common.  

This hearing was labelled “CMH” on the listings: it stands for “Case Management Hearing”. Their purpose is to review the case, and check things are moving along towards what’s needed for the final hearing.  In case like Peter’s, where the protected party is unhappy in their place of residence, judges often use the opportunity to try to improve P’s circumstances in the interim.  

Case management hearings generally seem to involve less by way of complex law and legal argument, and more by way of judicial application of common-sense and  leadership skills. They try to get people to talk to each other, to try to get health and social services working together, to explore what needs to be done next, and generally to provide oversight of the way individual cases are being managed.  I wish it didn’t need a court hearing to do this, but the brutal reality is that it does.  The prospect of being in court and accountable to a judge seems to focus practitioners’ minds.  A lot of activity seems to take place in the day or two before a hearing to move the case along.

HHJ Buckingham did her very best to ensure that Peter’s quality of life improves over the next few months before the next hearing.

Given the lack of progress between the last hearing and this one, I don’t know how successful her efforts will turn out to have been.

Celia Kitzinger is co-director (with Gill Loomes-Quinn) of the Open Justice Court of Protection Project.  She tweets @kitzingercelia 

When capacity for contact and sex do not align: Pragmatic decisions and judicial work-arounds

By Ruby Reed-Berendt, 24 October 2022

Having contributed to a previous blog on capacity to engage in sexual relations and the Supreme Court decision in A Local Authority v JB (Capacity to engage in sex: Nine responses to the Supreme Court Judgment in Re. JB), I was keen to observe a hearing on this issue to see the application of the law (and its direction of travel) since JB. 

I got the opportunity to do so on 18th October 2022 when Celia Kitzinger alerted me to a case which was being heard via MS teams in the Royal Courts of Justice (COP 13627568) before Mrs Justice Lieven.

In line with normal practice in the Daily Cause List for the Royal Courts of Justice, there was no information as to what the hearing was about (unlike hearings listed in the county courts where case descriptors are increasingly available).  However, Celia had observed and blogged about the case a few months earlier (“Grave concerns”) and recognised the case number in the RCJ lists.

At that hearing, the district judge (DJ Glassbrook) expressed “grave concerns” and said he was “unhappy” about the declaration he’d already made at an earlier hearing which (he said) could be interpreted as meaning that “if there is somebody who is new to P, she does not have capacity to go and sit with him or her in a café and have a brew, but can decide that a one-night stand is on”. 

At that point there was no “TZ-style care plan” in place, and there was a subsequent hearing (observed but not blogged by Celia) on 3rd August 2022, which further explored the issues based on a draft TZ-style care plan, but left DJ Glassbrook still unhappy.

“To say that she has no capacity to meet a stranger for contact, to have a cup of tea, but has capacity to meet a stranger for sex, is something that makes me scratch my head. And if that’s the parties’ position still, there a very easy answer. I’m going to pass it on. Because I have a problem with that.  If a High Court judge wants to make that decision, fine!” (DJ Glassbrook, 3rd August 2022, from Celia Kitzinger’s contemporaneous notes).

And so, this was the case now before High Court Judge, Lieven J.

THE HEARING

This was a short hearing – about 45 minutes from start to finish.

At the outset, the judge noted that some observers were present, and asked counsel for the applicant Local Authority (Lee Parkill of Cornerstone Barristers) to summarise the issues for our benefit. 

The case concerned a young woman (let’s call her Olivia) who spent time in a secure mental health unit before she turned 18 and now resides in a supported living placement with a three to one ratio of care (i.e. three carers providing care for one person). 

We were reminded that at a previous hearing in December 2021, DJ Glassbrook made orders that Olivia lacks capacity to conduct the proceedings or to make decisions about her residence, care, social media and internet use, as well as to decide on contact with others. She also lacks capacity to enter into a tenancy agreement. However, she does have capacity to engage in sexual relations. 

Olivia was not present at the hearing, but her best interests were represented by Jake Rylatt of Serjeants’ Inn Chambers (via the Official Solicitor). Her former foster-carer was also in court as second respondent, as too was a social worker (albeit not her ‘allocated’ social worker).

Capacity, contact and sexual relations 

The judge first dealt with DJ Glassbrook’s apprehensions about the state of the law:  

DJ Glassbrook has been very concerned about this case and whether the current state of the law really protects [Olivia]. And I must say, I have some concerns about the current state of the law, but that’s as set down by the Supreme Court and that’s not for me to go against[i]”.

The judge then made reference to another case which concerned capacity to engage in sexual relations, Hull City Council v KF [2022] EWCOP 33. She observed that, in that case, Mr Justice Poole had “found a clever way” to deal with a situation where there was an individual-specific concern. In the Hull City Council case, KF was considered to have capacity to engage in sexual relations in a general sense, i.e. she understood the act of sex, the requirements for mutual consent, the potential risks of pregnancy and infection, and the need to use protection. However, concerns arose about her capacity to have sexual relations with her partner, who had pleaded guilty to assaulting her (see Determining capacity for sex with her abuser). Poole J held that KF lacked capacity to engage in sexual relations with this particular person, having examined the risks in relation to him specifically, a risk which Lieven J considered to be “overwhelmingly obvious” in KF’s case. 

Returning to the current case, Lieven J noted that Poole J’s approach gave a “pragmatic way around the rather complicated way the law has developed in this field”, but that it wasn’t currently a relevant consideration for this case, given that neither party had identified any individual specific concerns in this area, although “there might be one in the future”.

The judge concluded these remarks by saying that “in light of the case law from the higher courts, I don’t think we have any choice but to go ahead with the TZ-style care plan solution”. She added that if Olivia were to get into a situation where KF-type concerns arose, a different order and care plan might be needed, but “that isn’t where we are at the moment”. So “really all I can or should do is look at that care plan and look at how it protects [Olivia] going forward”. 

The care plan

A TZ-style care plan is one that, in essence, aims to support the individual to develop relationships, including sexual ones, in a way that keeps them safe. The judge asked counsel to go through its key aspects so she could understand “where you are going with it”, highlighting at the outset “it would be useful to understand a little bit more about [Olivia]’s sexuality and her position in relation to wishing to have sexual relations.” She emphasised “I haven’t got a particularly good sense of [Olivia] at the moment. I appreciate she has serious mental health issues, but I haven’t got much of a sense about her relationship status, to use the youths’ terminology.”  

Mr Parkill summarised that the care plan’s purpose was to manage the conclusion of DJ Glassbrook’s order, i.e., that Olivia lacks capacity to decide who to have contact with, but has capacity to engage in sexual relations. The aim, he stated, is to support her to have contact with individuals, both in person and online, and to ascertain how care staff will support her in making choices. The judge’s questioning of counsel for the local authority revealed her focus on the specific risks for Olivia and whether there was evidence of this: 

Lieven J: Does [Olivia] have a history in engaging in risky sexual behaviours? 

Mr Parkill: There have been occasions of [Olivia] sharing photographs, but there has not been a presenting problem of her engaging in risky behaviour. 

Lieven J: So she may have problems in terms of safe use of the internet? 

Mr Parkill: Yes, that was the position of the expert, Dr Ince, last year and the social worker’s more recent assessment is that [Olivia]’s understanding has improved, but not to the point of capacity. The expert holds the view in time she will have capacity but she’s not there yet. There Is no proposal to impose restrictions on her use of the social media. The view taken is that to do so would be a backward step and would cause a degree of friction between her and carers, which would be very unhelpful. The amount of support she has provides the safety net to her to help her manage the risk.

Lieven J: And in the current care plan – I’m not criticising – you are not proposing to restrict her internet access or monitor access? You’re trying to get her to tell the care staff about what she is doing, rather than have checks on her internet use?

Mr Parkill: Yes. The aim is to develop the relationship with her carers – rather than impose restrictions which, naturally and understandably, she would react against. The plan then provides guidance about how to support her when she meets somebody in real life and where staff would be – would they be at a distance or with her… What needs to be worked out is how staff will make decisions about individuals if there are concerns, and how decisions will be made about restricting contact with an individual.

Lieven J: And the fact that [Olivia] does not have capacity to decide who to have contact with stems from the fact she is vulnerable and at risk of exploitation? Is this based on historic behaviour? 

Mr Parkill: I think it is based on her presenting a lack of appreciation of risks posed by other people.   

Lieven J: Not least because she has had wrap-around care throughout her childhood and young adulthood. This sounds great in theory [laughs], but young women like [Olivia] are open to exploitation. It’s well known, and I’m afraid a fair few have passed through my court. 

There was discussion about the types of activities which Olivia would be supported to undertake, both in person and online, to build relationships. The judge asked about contraceptive advice and was told that this, too, would be part of the plan. 

Mr Parkill mentioned use of online websites and in-person LGBT groups that she would be supported to attend. At this point the judge interrupted again: “This is what slightly confused me, and was why I hinted at the beginning that I wanted to understand her sexuality. Is that in order to be diversity-aware or something to do with Olivia herself?” Mr Parkill then clarified his understanding that it is because of Olivia’s views, but “I hesitate to paraphrase, as her intentions in respect of sexual partners are not entirely clear”. (Mr Rylatt later clarified that it was based on what Olivia had disclosed to her family – “she identifies as bisexual”.) 

Mr Parkill then went on to talk about online dating further: “Another strand of activity will be looking at websites she can access and giving her guidance about accessing those. We don’t want the plan to effectively operate as curtailing [Olivia]’s choice of sexual partner unduly, so we need to be cautious about restricting types of websites she can access.”  To this to the judge responded: “We also don’t want to be in the situation where care workers inadvertently support [Olivia] into a situation where she’s being exploited. The whole thing is fraught with difficulty“.

The intention was to prepare an Easy Read version of the care plan, once it was agreed, so that Olivia herself can understand it and appreciate what support (and what restrictions) she is subject to.

Further discussion of the care plan focused on what would happen if Olivia were to engage with someone who poses a risk to her, and what intervention would be required if this happened. The range of responses available (including police intervention as a last resort) was raised in detail by Mr Rylatt. The parties seemed to agree that if this were to happen, some intervention from her carers could be given: but if the local authority wished to restrict contact with an individual, the matter would need to return to court. This left open the option of a ‘KF approach’ (as counsel for the Official Solicitor put it), if one was needed (Hull City Council v KF [2022] EWCOP 33). It was also agreed that the care plan should be more explicit on this matter. The judge recommended, in addition, that contraceptive advice should form part of the care plan, which the Official Solicitor supported. 

On this basis, after checking that the care worker and Olivia’s foster mother had nothing to add, Lieven J agreed to endorse the care plan and make the orders. 

Residence

The judge then turned to discuss the matter of residence, which appeared to centre on the production of a tenancy agreement by a third organisation which was not Olivia’s care provider but was to act as the landlord. This was to be signed by the local authority on Olivia’s behalf, because Olivia lacks the capacity to enter into a tenancy agreement. It was not clear why there had been a delay in this organisation producing the tenancy agreement and they were not responding to requests for information.

The judge was clearly confused about the role of this third party, and had a discussion with Mr Parkill. (There had also been attempt at the earlier hearings before the District Judge to sort out this problem.)

Lieven J: I don’t quite get this. Is the city council in a contract with this organisation to provide care at this property? 

Mr Parkill: The care provider is a different organisation. 

Lieven J: So has the city council entered into a contact with this organisation to do something for [Olivia]? 

Mr Parkill: The contract is between the authority and the care providers who have bought the freehold. The care providers then contract to the organisation, who is the social landlord. 

Lieven J: Perhaps none of this matters, but I have become curious. Why has this organisation been brought in? Are they a registered social landlord? 

At this point the solicitor for the Local Authority answered: 

Solicitor: Yes they are the social landlord, and there would be a conflict if they were both care provider and social landlord. 

Lieven J: I suspect that is a cover for reducing the housing benefit. I can’t see why that would be a conflict.  

She then asked if there was any reason she should not simply make an order for the organisation to produce the tenancy agreement. Mr Rylatt expressed a preference for a further hearing, where the organisation could be asked to appear before the Court and give evidence on the tenancy. This was not something the judge felt was necessary, and she expressed concern about the potential for it to waste time and money: “Why are we having another hearing? We have far too many hearings in the Court of Protection – far too many ineffective hearings. I am not having another hearing just so this person can produce a tenancy”.

Mr Rylatt then suggested that another hearing was needed anyway to scrutinize and approve the care plan. The judge responded “I am not here to scrutinise care plans when everyone’s agreed, and there’s no point of law. I won’t fix another hearing. If the Official Solicitor thinks there should be one, then I will give her liberty to apply. Otherwise you can agree it and send to me“. To the suggestion that a hearing could be listed and then vacated, she replied: 

“Court of Protection cases are notorious for blocking up our diaries and being pulled at the last minute, and that is time which could be spent getting another child or another P through the court system. It’s also a way for money to be wasted, as lawyers are still instructed but the case doesn’t then happen. I would rather do it the other way round. So if I can persuade you to go away and sort it out and come back to court if you need to. But I would be flabbergasted if, once you’d had a proper discussion, agreement wasn’t reached.  How am I going to decide what is a safe website or not? How am I going to decide on the facts – or if the LA is being too protective or whether, to be frank with you, the Official Solicitor is being too cavalier and taking too many risks? That really has got to be one for the professionals to discuss. A clear timetable I can agree to, so this doesn’t get pushed into the long grass, but not another hearing.”

Mr Rylatt asked for permission to “restore the matter to court if it can’t be agreed” (granted) and confirmed that if agreement were reached, the care plan would be submitted to court. The judge concluded that this was a sensible way forward and ordered that the social landlord had 14 days to produce the tenancy agreement[ii].

REFLECTIONS

The judge’s discussion at the start of the hearing of the state of the law in this area demonstrated a level of disquiet about some of the contradictions which arise from the interaction between capacity for contact and capacity for sexual relations. Lieven J chose her words carefully (at one point apparently self-censoring with the comment, “I’m not going to say that because there are members of the public here”) but was clear that her hands are tied by the decisions of the higher courts and nothing could be done but look at the care plan. As she stated “I am not going to do something clever or say the Supreme Court was wrong or try to get around it“. She also identified that Poole J’s decision was a form of ‘work around’ for what was a difficult case and she was supportive of using a personalised approach to protect individuals from “exploitation” where risks became apparent.

To my mind, the need for judges to adopt creative or pragmatic approaches to reach decisions they feel comfortable with indicates that the state of the law is less than satisfactory. Based on this case and the KF case, it sounds as though this is the direction that decisions about capacity to engage in sexual relations may now be headed: a finding of capacity on a general basis, but with the opportunity for reconsideration where specific individual risks arise. An approach like this does allow for a level of personalisation for particular partners and concerns about Olivia being exploited. But it does also seem intrusive when it comes to Olivia’s ability to develop relationships, which, echoing my concern about the JB case, may now be dictated by her carers’ perception of risk – in this instance, what kind of partners might be risky ones. The opportunity to come back to court and scrutinise capacity again if such a relationship were to arise also means that Olivia’s capacity to have sex faces being questioned repeatedly: this was one of the reasons that, prior to JB, capacity to consent to sex was assessed on a general basis, as Baker J held in A Local Authority v TZ [2013] EWCOP 2322:

“To require the issue of capacity to be considered in respect of every person with whom TZ contemplated sexual relations would not only be impracticable but would also constitute a great intrusion into his private life” [§ 23]

Although we are not quite in this position of assessing Olivia’s capacity in relation to every potential partner, it seems to me that the approach taken in this case leaves open the option of examining her capacity on an ongoing basis, something that would not have been possible without JB and Poole J’s interpretation of it in the Hull City Council case.  

It was also interesting to see Lieven J take a clear position on what is good use of the court’s time and her approach of encouraging the parties, in the strongest possible way, to work through the issues and come to an agreement together. In a stretched public funding environment, such considerations are important, but it’s also worth considering whether this does offer sufficient safeguards for Olivia if no further check is taking place on the agreements made between the Official Solicitor and the Local Authority.

Whether the case will come back to court or not remains to be seen. 

Ruby Reed-Berendt is a PhD Candidate and Research Associate at Edinburgh Law School. Her research focuses on mental health and mental capacity law from a feminist perspective. She has previously blogged for the Open Justice Court of Protection Project (see: “Cancer treatment in the face of unknowns and expert disagreement“). You can check out her academic website to learn more about her work, and you can follow her tweets @rubyreedberendt

[i] All quotations are taken from contemporaneous notes made (separately) by Ruby Reed-Berendt and Celia Kitzinger, and cross-checked for accuracy after the hearing. While the quotations are as accurate as we can make them, it’s unlikely that they are 100% verbatim.

[ii] Editorial Note (by Celia Kitzinger): In view of our concerns about ‘closed hearings’, as discussed in a recent blog post, it is interesting to note that in this hearing Lieven J made a ‘without notice’ (or ‘ex parte’) order against an organisation not in court and not represented. She said so explicitly: “We have to give [the organisation] liberty to apply for discharge as it’s made ex parte”.  Hearings held ‘without notice’ to people/organisations who are subsequently effected by the orders and directions of the court are one (but only one) of the features I have identified of ‘closed’ hearings.  I realise now that I have seen other such orders made in other hearings, but without appreciating their significance at the time.  I suspect that such orders are not as ‘rare’ as has been suggested.


A ‘hypothetical’ marriage and a snowball rolling downhill

By Lorraine Currie, 20 October 2022

On 11th October 2022,  I observed a hearing (COP 13582321, via MS Teams) before Sir Jonathan Cohen sitting in the Royal Courts of Justice.

This was my first experience of literally dropping in on someone else’s life. 

I’ve previously attended a few hearings because of the involvement of the Local Authority where I worked as Mental Capacity Act (MCA) Professional Lead. For the past 15 years, my day job has been totally devoted to promoting the MCA and improving practice, particularly social work practice.  I’ve also written a Court of Protection protocol for that local authority and played a lead part in legal planning meetings for numerous Court of Protection applications: DoLS challenges, Judicial deprivation of liberty applications and welfare applications. 

I wanted to observe a COP hearing because I realise that my experience in this area is limited to the cases where I have been involved. I believe that I have helped to set a very high standard for the evidence that is required before an application to Court is made. I was keen to see a hearing relating to a case with which I’d had no involvement and to witness a hearing which may be about issues I hadn’t previously encountered. 

So, on a professional level I didn’t come to this cold but as an onlooker I found it strangely unnerving.

Gaining access

I followed the Open Justice Court of Protection Project’s very clear and helpful advice about how to observe. I emailed just after 8.00 a.m. and then when I received no response, I emailed again at 10.00 and eventually (after Celia Kitzinger sent emails on my behalf to the RCJ, to the video hearings administrator, and to the judge’s clerk), I received three email replies with the link at 10.30, 10.34 and 10.42 for the 10.30 hearing.

The hearing

This case (in my opinion) didn’t quite know what it was about.

It had a long history beginning back in 2020 when the local authority learnt that the young man at the centre of the case (P) planned to go to Pakistan and marry Z, who he would then sponsor to come and live in the UK.  P is in his 20s has a diagnosis of learning disability from early childhood and (more recently) autism.  At that point, P’s social worker was worried that P didn’t understand what marriage was and commissioned a formal capacity assessment, which confirmed that he lacked capacity to consent to marriage or sexual relations. This level of detail was not shared in the hearing but I was made aware of it later. During the hearing I was having to fill in the blanks.

There was a plan to provide sex and relationship education,  but the COVID-19 pandemic and a failure to locate educational providers intervened and so it was sometime later when an education programme to support capacity in relation to sex and marriage was completed. A newly appointed expert then assessed P again and said that P had still not gained capacity in these areas. 

It was stated that P lacked capacity in all other decision-making domains that had been assessed (including decisions about care and support, and internet-use), but that some further education may result in improvement in relation to some areas, but that education must be slow and at his pace. 

Subsequent to the expert report, P had a heart attack. This was something which no one apart from the Judge seemed to think was significant. 

Judge: And how does P’s unfortunate heart attack impact on all this? It happened eight days after [the expert] had signed off on his report – so where does that leave the report?

LA:  It doesn’t undermine the report in any way

Judge: No, I realise that a heart attack doesn’t make anyone’s functioning any better, but it may be that the young man [the expert] reported on is not the same young man who suffered this unfortunate event.  It may be that [the expert’s] view may be changed in the light of this heart attack. Or that may be completely wrong and it might have had no effect on P’s cognitive capacity.

LA: The court is not invited to say that P has capacity in any domain except the marriage one.

Judge: If it’s to be argued on P’s behalf that he does have capacity, how is the court to rule on it in the absence of an update from [the expert]. That’s my point.

LA: We can ask [the expert] to reassess him on that one point, consent to marriage, but we wouldn’t want to ask for reassessment across everything. We know from his parents that he found the process of assessment quite upsetting.

The Judge (and I felt the same) appeared to be somewhat puzzled as to why only two areas of decision making were singled out for the Court’s attention (marriage and sex) when five areas had been considered by the expert. 

Counsel for the LA seemed to think that these other areas in which P had been found to lack capacity were of no significance to the court because they were not disputed. They were, she said, not part of the LA’s application: the assessments had been carried out only to give a sense of P’s functioning. Capacity of internet use, she explained, had been added as an issue for the expert to report on  as it had become clear during the educational programme that this was an area of concern or ‘vulnerability’.

During all this to-ing and fro-ing, the parents of the young man sat in a quiet and dignified fashion listening to the comments. P himself was not present, but had a litigation friend (a friend of the family) who was.

It then transpired that P may potentially gain capacity to marry but is unlikely to gain capacity to engage in sex. This provoked a debate about whether marriage and sex were issue-specific or person-specific,  which counsel for the LA and the judge seemed to take a different view on.  They also disagreed about the implications of JB in the Supreme Court  last year (A Local Authority v JB (by his litigation friend, the Official Solicitor) [2021] UKSC 52.). When counsel for the LA gave an account of what the Supreme Court decided, the judge said, “I don’t think the Supreme Court said that at all”.  

The judge was also puzzled as to why he was being asked to make a ruling about capacity for marriage when there was no longer a proposed marriage partner, Z being “no longer part of future plans”. “Why is the court being asked to consider making what is a hypothetical decision?”, asked the judge, saying he thought he would “need quite a lot of persuasion” to do so, given that marriage is “a completely hypothetical issue at the moment”.

Eventually it became clear that the LA wished to implement safeguards or ‘protection’ for P in his best interests (e.g. in relation to social media use) and in order to do so would need to know if it was a decision he could make himself or whether in fact, he lacked capacity for this decision. The Judge was persuaded by this argument, but it led us to a much stranger place (in my opinion): the question of deprivation of liberty.

Counsel for the LA seemed to want, on behalf of the LA, consideration by the Court for specific restrictions only i.e., those which were or may be contested. She did not at any time consider, nor was she aware (she said) of the content of the care and support plan and therefore by implication any wider restrictions in it, which might amount to a deprivation of liberty. Counsel for P however, acknowledged it was very important to consider whether the restrictions as a whole amounted to a deprivation of liberty. 

I found it very odd that the full care and support plan had not been put to the Court but only what we might call edited highlights. Counsel for the LA said that “this isn’t a case where P is deprived of his liberty, so we don’t need the court’s authority on that”.  The judge responded (quite rightly in my view) by saying: “I simply don’t know if there’s a deprivation of liberty.  I mean, does he have a key to the house, can he leave when he wants, can he go out without an accompanying person? I simply don’t know what restrictions there are”. The Judge stressed that he understood the need for pathways but that these must cover the whole range of needs resulting in restrictions.

Even at this stage Counsel for the LA seemed to be surprised that (two years into proceedings) the Court wanted to now expand the issues and to see all the evidence about his care needs and the measures the LA think are required both to meet his needs and safeguard him.

So ultimately it seemed to me that 

  • The Judge was the person most concerned about delay
  • He was concerned that the timetable of events hadn’t been adhered to and wanted to “get this ship shape and make sure the next hearing is an effective one
  • A new significant health matter (the heart attack) had arisen and not been addressed in the reports
  • Some elements of care were giving rise to restrictions, but others had not been put before the court because of agreement about their necessity.

The Judge asked the parents if there was anything they wanted to say, and they gave their commitment to work with the doctor or anyone else to best support their son.  The judge said: “I’m very grateful and I’m sure he’s very grateful for all your love and support. It makes a world of difference!

Reflections

I was left with the overall feeling that this case had snowballed out of all recognition. Perhaps an initial panic at a proposal to marry had rushed them to Court when they were not properly prepared. I suspect this snowball will continue to roll as matters relating to deprivation of liberty are now attaching themselves to it.

I was shocked that there are still misunderstandings about the correct test for sexual capacity and more shocked that a LA could present one or two selected restrictions to a Judge in the hope they would be approved without a picture of the totality of arrangements being gathered. It seems that P lives with his parents, therefore this would require a so called ‘judicial dol order’ should the restrictions meet the acid test (complete or continuous supervision and control and not free to leave).

Taking the issue of capacity to engage in sexual relations first,  I think that I was shocked to hear the debate as to meaning and interpretation, discussed in Court. I would quite expect to hear argument as to capacity but not to interpretation at this level with Counsel and the Judge disagreeing about the Supreme Court decision. It made me wonder how P’s rights would be upheld if there was still such confusion. 

I was most shocked by what appeared to be a total lack of understanding by Counsel for the LA that all restrictions in a care and support plan must be seen as a whole to consider whether this gives rise to a deprivation of liberty. The idea of taking one or two restrictions for a Judge to approve when the Judge was in total ignorance about what we might call the ‘concrete situation of the individual’. From what I heard, it sounds as though the acid test is met – and yet this appears not to have been considered by the LA. Why have they not followed the re X procedure to take the arrangements to Court prior to issues of marriage arising? 

This does not bode well for the Liberty Protection Safeguards which will, unlike DoLS, encompass all settings. LAs need to scope the extent of cases they will need to authorise in the future and that includes those where there is total consensus that the arrangements are in the person’s best interests. 

The case will be listed to be heard again in December.   

Lorraine Currie is now a freelance Mental Capacity Consultant. She has over 30 years Local Authority experience, is a qualified social worker and in 2021 received the LGC Award for Outstanding Individual Contribution. Lorraine provides extensive training and is currently completing work with Neil Allen on the BIA to AMCP Conversion course.  She tweets @CurrieLorraine

A property and affairs application: Observations about P’s role and who should pay costs

 By Georgina Baidoun, 20 October 2022

from Courtel/CourtsServe listing

This was the first time I had observed a full day hearing.

In response to my request to watch it, I received the following email:

Please see the below response from Her Honour Judge Cronin.
“Could you say that we won’t start until 10 and I will need her to explain who she is before we start – this is an application for deputyship for property and affairs
.”

Rightly or wrongly, I interpreted this as suggesting that no-one would knowingly want to spend their time like this! Seeing a glimpse of the judge’s sense of humour during the hearing, I think I was right.

I explained that I had been a Deputy for Property and Affairs myself and duly received the link. 

The judge introduced me to the others in attendance as an ‘experienced observer’, which I am fast becoming, who was aware of the rules of confidentiality. (I was not sent a Transparency Order.)

The hearing

The salient details for me were as follows.

P had been hospitalized several years ago and, having been diagnosed with dementia, had been discharged into a care home as a result of arrangements made by the Local Authority (LA). 

The LA didn’t seem to have made any attempt to find out whether she had any family, although in fact she had four children, one of whom was the applicant in the case. They had all become estranged from her some 25 to 30 years ago, after she had divorced their father and moved 250 miles away with the intention of establishing a new life for herself. 

The applicant P’s son, represented by Ms Naima Asif of Pump Court Chambers, said that he had first decided to look for his mother in 2016 but had had no success. He was inspired to try again when another member of the family informed him that his mother’s brother had died intestate and someone was needed to register the death, sort out the arrangements for the funeral and deal with the estate, of which P was the sole inheritor. In the process of taking responsibility for these arrangements, it was suggested to him that he might find his mother by getting in touch with the LA of the area where she was last known to have lived. This quickly resulted in a reunion. She had not really known who he was but she is reported to be happy to see him when he visits and when he takes her on outings.

He had then decided to apply to become the COP deputy for his mother’s property and affairs so that he could act for her as executor to his uncle’s will and ensure she obtained the benefit of her inheritance. 

Unfortunately, the timing of his reappearance in his mother’s life had led the care home and the LA to suspect that he had only sought out his mother so that he might benefit from the inheritance himself.

The respondent was one of P’s daughters (daughter A).  She did not cast doubt on the applicant’s abilities or trustworthiness but thought she would be better suited to the role, or should at least be joined with him as co-deputy. She was not in court and had apparently failed to attend a previous hearing too. She had also not filed a witness statement, as ordered at the previous hearing.

The LA was not a respondent but was ‘in attendance’, and legally represented by Ms Emily Price of Deans Court Chambers. The applicant’s barrister asked why it was necessary for the LA to give evidence since it was not a party to the application and did not oppose it. I haven’t recorded the judge’s response but Ms Price went on to take a major role in the proceedings.

Also present was P’s social worker whom the judge described as being there ‘to assist the court’ in respect of P.

The LA did not oppose the application but was concerned about whether the applicant would be able to perform the role of deputy and whether he could be trusted. 

The judge considered the size of the uncle’s estate, which was now P’s inheritance, to be ‘limited’. The LA took a different view, comparing it with the assets of most of the people they dealt with. (I felt this was a significant difference in perspective which had led the LA to act in a way that I personally found to be disproportionate.) The LA had also had concerns that the applicant intended to move his mother to a care home closer to where he lived, which they believed would be contrary to her best interests, but the applicant had now assured the court this was not his intention. Furthermore, he was not applying to be a deputy for health and welfare and so would not have the authority to make such a decision (which the LA must have known).

The LA had suggested that P’s assets would be in safer hands if the applicant were to be joined by a professional solicitor as his co-deputy, at least temporarily. The applicant was resisting this because of costs, as he wanted to maximize the benefits that his mother could obtain from her money in terms of treats, outings and other extras not provided as part of the standard care home package. 

The LA’s concerns came mainly from the social worker and the care home. The care home had been asked by the court to file a statement but had not done so. However, they were reported to have said that there had been far fewer visits and contacts than the applicant claimed. The social worker was concerned about P’s response when she was formally notified of her son’s application to take over the management of her finances (recorded on form COP20A about which I have given my opinion in another blog. The response P gave to this news was quoted verbatim and was a combination of distrust and confusion, as might be expected from someone with the degree of dementia described by the social worker as well as by the applicant and one of his sisters (daughter B) who had also visited. This sister was present for the latter part of the hearing and gave evidence in support of the applicant. The respondent (daughter A) was not known to have visited or made any contact despite claiming she was best placed to act as deputy. 

The social worker expressed concern that, if the applicant succeeded in his application, ‘they’ would not know what was happening to P’s finances until ‘the money had run down’. Questioned by the applicant’s barrister, she professed to know that the Office of the Public Guardian would be requiring an annual report and agreed that this ‘reduced her concerns’.

The LA’s barrister spent a great deal of time rigorously questioning the applicant’s evidence about the length of time he was estranged from his mother, whether he had really tried to find her before he discovered she had inherited money, and whether he had in fact visited and kept in touch with the care home as much as he said. He had already produced in his written evidence photographs of his mother enjoying outings on which he had taken her and had provided the dates, but Ms Price insisted that he find the originals on his phone and hold them up to the camera so the dates could be verified. She suggested that, if he wasn’t able to visit P more than two or three times a year, he was unlikely to be able to find the time to act as deputy. The applicant said that he hoped to visit more frequently in future but that it was a round trip of 500 miles and he had a business to run. There were also problems with the prohibitions and uncertainties of arrangements for visiting care homes as a result of the pandemic.

Ms Price went on to challenge the applicant about exactly how he expected to spend money to improve the quality of P’s life, for instance whether he had explored how he would find a paid carer to take her on outings between his and his sister’s visits. She suggested that a paid deputy would be better able to perform the role, which I personally doubt given that the duties concern property and affairs, not health and welfare. I really had to wonder whether this kind of questioning was appropriate. She also suggested that the applicant taking on the role of deputy would not be in P’s best interests because it would exacerbate the difficulties that had arisen between the siblings as a result of his application.

Some of these questions were also put to daughter B who joined the later part of the hearing. She had also visited her mother and said she made regular phone calls to the care home to ask about her welfare, although the care home was reported to have said her calls were ‘infrequent’. After hearing her responses, the applicant’s barrister noted that daughter B would seem to be an appropriate person to join with her brother as deputy; daughter B had said she was prepared to accept that role although she was not joined in the application.

Ms Price’s closing submission on behalf of the LA reiterated concerns about the lack of regular visits and how this would make it difficult for the applicant to understand P’s ‘day-to-day needs’. She also referred to concerns set out in the respondent’s statement which, because of her non-appearance, were not part of the hearing. She expressed the hope that the respondent’s relationship with her mother might improve over time (but since she had not seen her for the best part of 30 years and her mother’s dementia was getting worse, this hope could at best be described as unrealistic in my opinion).

The judgment

The judge gave an ex tempore judgment to be followed by a written decision, if requested, within the next few days. I have been told that no such request was made and therefore there is no written decision.

She rehearsed all the details of the case and said it was clear from the evidence provided that P lacked mental capacity to manage her own financial affairs. 

She had considered the respondent’s view that she could perform the deputy role at least as well as the applicant but noted that the evidence she had supplied mainly concerned P’s health and welfare, which were not the subject of this application. The respondent had also suggested that the applicant might misapply some of P’s funds, but this had not been raised at the hearing and the judge did not consider it likely. 

The judge noted that the LA was not objecting to the application but had ‘properly raised a series of questions which had expanded as the day went on’. Her opinion was that most of these questions had been satisfactorily answered and that the safeguards that would be provided by the oversight of the Office of the Public Guardian would be ‘more than adequate’. Importantly for me, she said that she was ‘placing no weight on’ P’s response to being notified of the application.

The judge said she was not concerned about further breakdown of relationships between P’s children as a result of the application because this would have no impact on P herself or on the applicant’s performance of his deputy duties.

In response to the issues raised about the geographical distance between P and the applicant, the judge did not consider that these would affect the day-to-day management of her financial affairs, which would normally be done on-line by whoever undertook the task. The applicant was clearly a trustworthy and competent business man and had demonstrated his on-line competence by the way he had participated in the hearing. 

The applicant had a closer connection to P than either the LA or the respondent and could provide the ‘personal touch’ that neither the LA nor a professional deputy could provide. The judge proposed that daughter B who had joined the applicant for the hearing should also join him as deputy, and she agreed to this. The judge hoped that this would reassure the respondent as well as being advantageous for P in making it more likely that at least one deputy would always available.

Costs

The general rule is that the costs of deputyship applications should be met from P’s assets, although there are exceptions: for example, see another previous blog, which reports on a case where, unusually, an applicant had to pay costs in a Property and Financial Affairs case as a penalty for wasting the court’s time.

In the current case, as in the one previously blogged, the judge was asked to consider making legal costs the responsibility of the party who had opposed the application and whose lack of engagement thereafter had prevented a possible earlier settlement. The respondent had refused to engage with solicitors, failed to file a statement when required by the court and failed to attend two hearings. The applicant’s barrister considered the position taken by the respondent in asking to be appointed deputy had also been unreasonable. 

Interestingly, despite the obvious parallels with the previous case about which I wrote, this judge decided not to penalize the respondent for her conduct. She made it clear that her decision was not affected by the respondent not having been legally represented. Instead, she made her decision based on what was known of the respondent’s circumstances, which suggested she would be unable to afford even a part of the costs (for the applicant’s legal representation only, which amounted to over £14,000). Also, if she were asked to pay, it would only exacerbate the already strained sibling relationships. This was the only point of difference I could see between the two cases. 

Georgina Baidoun was the lay Court of Protection Deputy for her mother’s Property and Financial Affairs until her mother died last year. Because of the difficulties she experienced with several applications to the Court, and with the Office of the Public Guardian in connection with her annual report, she has retained an interest in these areas, including attending recent Court of Protection Users Group meetings. She is keen to share her experiences in the hope that she can help others who have to engage with these institutions with very little help or guidance. She tweets as @GeorgeMKeynes

Cancer treatment in the face of unknowns and expert disagreement

By Ruby Reed-Berendt, 18 October 2022

A man (MB) in his 30s has been in hospital (and deprived of his liberty) since May 2022 after his mental health deteriorated. Although there remains uncertainty as to the cause of his poor mental health, there is a working diagnosis of T-cell lymphoma of the nervous system. Newcastle upon Tyne NHS Foundation Trust seeks a declaration that he lacks capacity to make decisions regarding treatment of the suspected disease, and that it would be in his best interests to receive chemotherapy. 

By the time the case came before Mrs Justice Morgan (COP 1398600T) on 27th September 2022, there was agreement between the Trust and MB’s litigation friend, the Official Solicitor, that MB lacks capacity to make decisions about treatment for his lymphoma. The sole issue presented for consideration by the court is whether MB should receive two cycles of chemotherapy. Whilst this is not an entirely novel form of treatment, its proposed manner of delivery is. Due to the extreme changes in MB’s condition and his reported level of “emotional dysregulation”, it would need to be given in intensive care (ICU), with MB intubated, ventilated and sedated. The parties agree that treatment could not be delivered in a less restrictive setting and could constitute a deprivation of MB’s liberty. The full facts are set out in Morgan J’s judgment which is now available: Newcastle upon Tyne NHS Foundation Trust and MB [2022] EWCOP 43.

The hearing was carried out in a hybrid format (some parties were present in a physical court room and others joined remotely). I observed the case online across two days and heard evidence presented to court from:  

  • MB himself, who spoke with the judge in private at the start of the hearing, and “does not believe he has cancer or has ever had cancer
  • Members of MB’s family, who relayed their views via Miss Emma Sutton, counsel for MB via the Official Solicitor, towards the end of the second day. 
  • Six medical witnesses, whose evidence formed the bulk of the hearing. The six witnesses were consultants working in haematology/oncology, intensive care, and psychiatry. In each speciality, one witness worked for the Trust, and the other was an independent expert instructed by the Official Solicitor. 

Throughout the case, what struck me was the extent of uncertainty and unknowns in this case, and how “finely balanced” the decision was. It also meant that the expert evidence was far from unanimous, with numerous points of distinction, and each consultant came from their own perspective based on their past expertise, and their experience of interacting with or examining MB. These opinions were revealed through examination-in-chief and cross-examination, a process where counsel for the Trust and the Official Solicitor ask questions of the witnesses and seek to challenge their opinions. As the judgment outlines the facts in detail, in this blog I focus instead on how these views were drawn out through counsel examination.  

Diagnosis and prognosis 

The first major uncertainty surrounded MB’s diagnosis of T-cell lymphoma, which was the focus of the haematology evidence. It was described by Mr Rhys Hadden, counsel for the Trust, as a “best guess”, but no other alternative diagnosis was considered likely by the parties. On top of this uncertainty, T-cell lymphoma was described as very rare and especially within the brain. MB’s cancer was progressing much slower than most other cases and was seen as atypical and as such the witnesses were uncertain about prognosis.  

The first witness to give evidence was Dr Nicholas Martinez-Calle, consultant haematologist and an independent expert. In his evidence he emphasised that T-cell lymphoma was “rapidly growing and aggressive” and that having looked at the evolution of MB’s symptoms and the decline his in “psychiatric behaviour”, his view was that the condition would be lethal within 4-6 months if treatment was not given. Miss Sutton in her examination-in-chief pressed him on whether MB’s deterioration was actually caused by his illness: 

Miss Sutton: Could an alternative reason for MB’s mental health decline be that he’s been deprived of liberty and wants to go home?  

Dr Martinez-Calle: There is clearly an organic cause. Radiological imaging demonstrates there are changes in his brain that could account for his behaviour. The psychiatric manifestations are novel and a consequence of the lymphoma.  

This questioning was helpful in exploring the other causes for MB’s distress. Mr Hadden also pushed Dr Martinez-Calle in cross-examination on his view on MB’s prognosis, which also drew out the atypical nature of his progression:  

Mr Hadden: If MB’s current condition were not treated, you said the prognosis is effectively 4-6 months. What is your opinion based on? 

Dr Martinez-Calle: It is an estimation that is likely to be accurate. The survival of brain lymphomas if left untreated is normally very short, weeks probably. I am being conservative because I know the progression of the disease has been slow compared to what we are used to, but it is expected to continue progressing into sensitive aspects of the brain that will risk his life. Although the disease might not grow in volume, it might grow in sites that will cause rapid deterioration.  

The Trust haematologist, Dr X, was the last witness to give evidence and it was clear that she had reflected carefully on the evidence she had heard (she attended most of the second day remotely, so had the benefit of hearing from other witnesses). Based again on MB’s unusual progression, her view was different – and this was drawn out through Mr Hadden’s examination in chief: 

Mr Hadden: what is MB’s prognosis if the cancer is left untreated?

Dr X: It is hard to say. This is a working diagnosis of lymphoma causing damage to brain tissue. If we assume we are correct, we are dealing with a low-grade end, cells that divide slowly. I don’t think this is typical in any sense and it is clear from psychiatric assessments and history from family that he has been not well for 18 months, which is quite slow for T-cell lymphoma. So prognosis without treatment is likely measured in short years using what has already happened.  

Mr Hutton: We have heard evidence of psychiatric deterioration since hospital admission in May. Have you seen further deterioration?  

Dr X: I would say we have not. I would agree that his behaviour is different now. The question we are wrestling with is whether that is due to the disease or effect of environment and restrictions of liberty. I would concur there has been a change.  

Mr Hadden: So your view is different from that of Dr Martinez? 

Dr X: It is difficult. This is not typical and, normally, for nervous system lymphoma rapid deterioration is more normal. We just haven’t seen that and I’m inclined to think a slower prognosis.  

What both exchanges demonstrated just how uncertain things were for MB in terms of the impact of his illness on his life, and also how those assessing him evaluated his behaviour in different ways; where Dr Martinez-Calle saw deterioration caused by disease, Dr X was more open to alternative causes. 

The proposed treatment

The second uncertainty surrounded whether the treatment would actually work. Whilst the proposed treatment is effective in B-Cell lymphoma, it is novel and “one could call experimental” for this type of cancer. Mr Hadden also noted that approval was being sought for the initial phase of HDMTX and if successful “this won’t be the end of it” and active consideration will be needed as to what should happen next.  

A figure of 20% chance of success rate was referenced throughout the hearing and in the judgment, but each of the experts brought a differing perspective on what effectiveness and success would look like and how this figure had been arrived at. Dr Martinez-Calle stated the 20% was an “extrapolation” of the B-Cell lymphoma literature, and considered success to be “radiological improvement, survival and neurological improvement”. He also suggested that treatment would be useful in that it would help demonstrate whether the diagnosis was correct, as if it was not the treatment simply would not work. He certainly appeared to be the most optimistic about proceeding with the treatment and attempting more aggressive forms of chemotherapy after it. It was however clear that the 20% figure was by no means a certainty and may have been produced to assist the court more than anything else, as was drawn out in Miss Sutton’s cross-examination of Dr X:

Miss Sutton: The 20%, where did that come from?  

Dr X: You’ll appreciate this is difficult. I tried to estimate the incidence of this kind of disease as we don’t have a lot of data, about 1-1.5 cases per 10 million population per year. Even B-cell is rare (170 per year). We are in the realm of the case report here, and I am aware of 1 other case reported. We work closely as a team as you get a spectrum of views. So the 20% comes from the question of have we got the diagnosis right or wrong, if the treatment works or doesn’t, if there is brain recovery or if there is none. So whilst I’m confident the T Cells will die, the chances of that happening are 70-80%, whether that reflects in a better outcome is something we will find out.  I used the word “trial of therapy” in my statement and I would stand by that. It was a number put forward to give some idea to the court, but you are right that it is an opinion.”  

Miss Sutton also questioned Dr X on why she felt this treatment should be embarked upon now instead of waiting a little longer: 

Miss Sutton: Why not watch and wait if MB’s prognosis is in years?  

Dr X: The rationale is, what are we watching and waiting for? I don’t see a better window to do this. We need to decide that either there is a rationale for proceeding or that there isn’t. My worry about deferring the decision is it becomes less and less reversible. The caveat to that is if we have the diagnosis wrong, but as you can see from the papers we have had an array of experts and specialties give their opinion. 

Dr X noted that if the diagnosis is correct and the treatment works, the question was then how much brain injury was reversible. To her, “Success would mean arresting progression and improving cognition to some degree. Level of functioning, being able to recognise family, seeing how much support MB might need with everyday life even in a successful outcome.” She felt that if improvement lasted five years and MB could have an improved quality of life out of hospital, it would be a success. 

Dr Y, consultant liaison psychiatrist at the Trust also supported the treatment going ahead, focusing on the question of whether the damage to MB’s brain was reversible. This was brought out most clearly in cross-examination by Miss Sutton. When asked about the chances of recovery, Dr Y stated: 

We haven’t been able to do more detailed testing to work out what areas of functioning are affected. Dependent on this, global functioning might improve but won’t be back to pre-morbid function and likely there will be residual difficulties. Early symptoms include poor judgement (leaving cooker on, walking into the road without looking), they relate to frontal lobe atrophy and might remain. But memory might improve, as might functional tasks.”She however concluded it would be “unfair not to give him a chance”, with her focus on the aims of the treatment to not only improve his delusional beliefs, but also prevent “deterioration of a wider cognitive dysfunction and executive function.” Her evidence on quality of life was that if the treatment could allow him to function more independently it should be attempted.” 

The views of the intensive care specialists were more mixed. Dr Z, consultant anaesthetist at the Trust, supported treatment but emphasised the chances of success were low, again citing the 20% figure: 

I think he is in an extremely unfortunate position no matter what happens. If we don’t offer treatment, he is extremely unlikely to be better off, and much more likely to develop further problems and die. He is in a restricted environment already, the options he has will be more or similarly restrictive. If we do offer chemotherapy, chance of benefit is low but it is measurable. I think it’s less than 20% and his tumour may already have caused fixed deficit so I think that is his only chance. He probably won’t make a full recovery even with chemotherapy. I don’t think any of us are going into this with our eyes closed. We know doing nothing is an option and there is a spread of opinion in intensivists. The majority opinion is we should offer this trial, it is less likely to benefit him than not, but I feel it is in his best interests.”  

Dr Chris Danbury, consultant intensive care physician (the independent expert), took the opposite view, considering that the case was finely balanced but he felt that “we will probably do more damage to MB by admitting him to intensive care”. He focused heavily on the risks of admission to ICU and the potential mortality from infection. His emphasis was on MB’s quality of life, rather than its duration, and the lack of certainty in this case led him to conclude treatment should not proceed: “If I was more certain about the benefits of chemotherapy on his neurocognitive state, I would be more certain. My understanding of the imaging is it’s sufficient to explain symptoms, so I am not convinced the chemotherapy will make a difference.” 

The picture I gained from hearing these competing views was the complexity of assessing what benefit MB might derive from treatment, what his life would be like, and whether this made the risks worth running. Dr Danbury on the one hand was significantly concerned about the chances of infection in ICU and the impact this would have on MB’s quality of life. Dr X felt that even if there were “marginal gains” (as Miss Sutton put to her), that this still needs to be attempted. This chimed with Dr Y’s view that MB at least ought to be given a chance to get better. It was interesting to see in the judgment that the judge aligned with the latter view and adopted a human rights perspective to support her approach: 

“I accept that having the treatment may if successful prolong his life and that the starting presumption is protection of his life; that the right to life carries with it strong weight and that even and although the estimate of success is put at 20 % within the context of Article 2 EHCR that is not negligible. Even the most pessimistic of the evidence before me does not suggest the treatment is futile.”

§88, Newcastle upon Tyne NHS Foundation Trust and MB [2022] EWCOP 43.

One ITU admission or two? 

Whilst the parties agreed that the treatment would need to be take place in ICU, the witnesses also provided differing perspectives on whether both cycles should be attempted in a single ICU admission (i.e. up to 15 days of continuous ventilation and sedation) or two admissions of approximately 5 days with intubation and extubation (the placement and removal of a tube in an individual’s windpipe to administer drugs and oxygen) and the beginning and end of each of those periods (and a gap of 1-2 weeks between cycles). The delivery of treatment in ICU is considered to be particularly ‘novel’ and had not been attempted in the Trust before. The psychiatric and intensive care evidence focused heavily on what form of ICU admission was best, with the witnesses again offering slightly different perspectives. 

When it came to the intensive care specialists, Dr Z favoured two admissions based on MB’s youth and physical fitness, and Dr Danbury preferred a single admission based on an increased risk of MB experiencing Post-Traumatic Stress Disorder (PTSD) and delirium. To me, a key challenge here seemed that MB was not being admitted to ICU because he needed life-sustaining treatment: he was being admitted as a healthy young man in order to give chemotherapy under sedation, and for Dr Z, this changed the risk profile and pushed the discussion further into hypotheses and ‘unquantifiable’ risks. For example, when Miss Sutton pointed to Dr Danbury’s differing opinion, Dr Z responded: “It is not accurate to equate this patient to standard ICU admission. The question we should be asking are what the extra risks are for this patient of intubation/extubation.” 

Dr Danbury’s clinical focus however was on the psychiatric evidence and his concern that MB’s mental health challenges would be made more difficult by the intubation and extubation process. This led him to believe one admission would be preferrable if the treatment were to be attempted.  In spite of their disagreement, both recognised that there would be a ‘spectrum of views’ within their specialty and that there was perhaps no right or wrong answer. 

Whilst both the psychiatrists favoured one admission, their focus on the risks of two admissions was also slightly different, and the reasons for this came out through cross-examination when Dr O’Donovan, the consultant forensic psychologist (the independent expert) was questioned by Mr Hadden. The differing opinion on PTSD is reflected in the judgment, but another point which was discussed in the hearing was the potential damage to MB’s therapeutic relationship with his treating team, especially if he became aggressive and had to be restrained. Dr Y had previously given evidence that she was not convinced that MB recognised his clinical team and that she was “not sure therapeutic relationships are fragile”. This led to the following exchange with Dr O’Donovan which clarified why she considered this to be a risk: 

Mr Hadden: Dr Y was less convinced [about damage to the therapeutic relationship] as she was less certain he recognised his clinical team and he maintains the belief he works on the ward.  

Dr O’Donovan: It is important to look beyond the individuals and the environments. He does feel a degree of safety in that the episodes of distress are short. Whilst not being able to identify people by name, he feels on same level they are not complete strangers, because he responds quickly to the de-escalations that have been tried.  

The psychiatric evidence had a clear impact on members of MB’s family who attended the hearing, and when Miss Sutton conveyed their views, their concern for delirium came across strongly. This was hardly surprising given that both Dr Y and Dr O’Donovan viewed delirium as almost a certainty, but the family’s take on it was an important reminder about how hard this information must be to hear.

Concluding reflections

The assessment of best interests in this case appeared to be particularly challenging because of the number of uncertainties – the diagnosis, the chance of the treatment being successful, the manner in which the treatment will be delivered, the chance of recovery. The involvement of three distinct specialties with different expertise, drawn out through examination in court, provided the judge with a significant amount of information for her decision, even in the face of considerable ambiguity. Five out of six of the experts came to the conclusion that proceeding with treatment was the best course of action because it aimed to prevent further deterioration, and some of them did this through reference to what they would want for themselves, or for a family member. As Dr Martinez-Calle summarised: 

I try to look at cases where the patient lacks capacity and think what we would do if we could have a conversation with the patient and what we would say… It is what I would do in a similar case if they had capacity. The decision to treat is very clear, and the question for the court is whether the means we need to give the treatment are proportionate.”

As noted above, Dr Danbury did not share this view and felt if he had been approached by haematologists in his hospital, he would not offer treatment. He focused in particular on MB’s quality of life, because “this is not curable, so trajectory at the end is generally applicable but you are moving the time.” 

It was also clear that all parties felt the burden of the decision keenly. It seemed to me that the treating clinicians were grateful to the court process for allowing them access to independent expert opinion and an opportunity to “thrash things through”. I was struck by their compassion for MB and their evident wish to do the right thing for him, even if identifying this was incredibly difficult. The clinicians were also clear in their evidence that they would be happy to proceed in accordance with what the court determines and would be open to the options of one or two admissions to ICU. Here, I felt the hearing also served a purpose of not only making a decision, but allowing someone independent to make the decision instead of the treating team or the family. A potential anxiety or guilt over doing the wrong thing was conveyed clearly by Miss Sutton when she provided the family’s view:  “[Relative A]’s personal view is the treatment should be attempted and she would like him to try to have it. She wants no responsibility to be placed on her shoulders so she would have a guilty conscience.”

To this, the judge quickly responded that although she wanted to know what the family thought and felt, “it is a decision for me, not for them. Nobody is asking them to make a decision and it is not a decision for them to make.” 

Although I could not see how the family in the hearing reacted to her response (their cameras were turned off), I hope that her clear response offered them some of comfort. 

The medical evidence was discussed throughout the case, as was how to manage MB should he resist the treatment (e.g. with the involvement of a liaison psychiatry team in the acute hospital). It was notable that it was discussed at far greater length than the views of MB and the views of his family. This is perhaps unsurprising given the complexity and variety of medical issues, and that MB’s current views were not (based on the judgment) considered to represent his true views. Similarly, before the final witness gave evidence, the family were largely supportive of treatment going ahead. MB’s family members suggested that MB would want the treatment because he would want to live for his family, and it is this that the judge appeared to rely on when she ascertained that this would be his wishes if he had capacity (paragraph 89 of the judgment). However, I wondered if there could have been more opportunity to consider what MB’s views would be if he did have capacity in the oral hearing. I did not feel that any real picture was given in court of what kind of person MB was, his feelings about his family and other views which might be relevant to the best interests decision. 

In the face of all this uncertainty, the judge was left with an unenviable task of deciding what to do, and she came down in favour of treatment through a single admission to ICU. 

This may not be the end of court proceedings for MB.  If the treatment is successful (and if the success is quantifiable, which seems far from certain), it seems likely that the matter will return to court at some point in the future. Given the fine balance of this case, it may be impossible to ever know if the ‘right’ outcome was reached. 

My main hope is that MB’s family have been relieved of any burden they might have felt, and although the court process must have been incredibly hard for them to hear, they are able to enjoy whatever time they have left with him. 

Ruby Reed-Berendt is Research Associate and PhD Candidate in the School of Law at the University of Edinburgh.  She tweets @RubyReedBerendt