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Would I lie to you baby, would I lie to you?

 

 

I think Mostyn J might have preferred my original choice of title “supressio veri, suggestio falsi”   as he makes that reference within the body of the piece.  But what sort of King Canute am I, to attempt to stand in the course of the Charles and Eddie tide when it comes crashing in?

 

This is a Court of Protection judgment, in which the Court was being asked not only to approve treatment to a woman AB, who lacked capacity to consent to it, but also to actively deceive her about the treatment.  Not just to ‘supressio veri’ and conceal the truth from her, but ‘suggestio falsi’  to actively lie about it.

 

  1. I am asked to approve a treatment regime for AB, which involves the administration of medication to her on a basis of deception. Not merely passive deception, which, to use a legal phrase might be characterised as suppressio veri, but active deception, which lawyers might describe as suggestio falsi. It is debateable whether there is in fact much moral difference between the two types of deception, but what is being proposed here is a treatment regime, an administration of medication, on the basis of active deception of AB.

 

Re AB 2016 EWCOP 66

http://www.bailii.org/ew/cases/EWCOP/2016/66.html

 

Mostyn J sets out that it is unusual for the Court of Protection to be asked to decide that it is in a patient’s best interests that they be deceived , and that he has not come across such a case before.

 

The facts are tragic, and explain why that was felt to be desirable.

 

  1. As I have stated, AB is HIV positive and she had contracted the disease by 2000, when she was diagnosed with it. She was of full capacity at that point, and she voluntarily sought treatment and engaged fully and consensually and willingly with such treatment until 2008.
  2. In 2008 there was a major deterioration in her mental condition, and after that her engagement with HIV treatment was interrupted. Her medical condition worsened, and I heard evidence from Dr L, consultant psychiatrist, specialising in the field of rehabilitation psychiatry.
  3. She has described to me how AB suffers from a serious psychoaffective disorder. Her evidence demonstrated to me that, although people who suffer from this disorder do, from time to time, recover, the extent of relapses in this case, and their scale, means that in her opinion it is unlikely that in the foreseeable future she will recover from her psychiatric condition. Her psychiatric condition means that she is unquestionably incapacitated under the terms of the Mental Capacity Act 2005, in relation to the decision whether to engage in anti-retroviral treatment.
  4. She was visited just the other day by a member of the Official Solicitors’ staff, who has produced an eloquent attendance note. If anyone has any doubts as to the scale of the mental challenges faced by AB they only need to read that note, which I am not going to read into this judgment.
  5. Suffice to say, that she is in the grips of very powerful delusions, which prevent her from addressing many aspects of normal life rationally. For example, she does not believe that, now, she is HIV positive. She believes that she is a participant in a film about HIV, in which she will be participating with her husband. She does not, in fact, have a husband, but she believes that she is married to a celebrity sportsman. She believes that the person who is her husband will come back for her and take her away to live in connubial bliss. She believes that when blood samples are taken from her by the hospital staff it is done by them for the purposes of drinking her blood. Above all, she is positive that she is not HIV infected, and were she to learn that she was being secretly and clandestinely administered with anti-retroviral treatment the evidence is that she would be exceedingly aggrieved.
  6. If the choice were hers, and hers alone, she would not take the anti-retroviral treatment and, on the evidence, it is clear that, were that course to be followed, having regard to previous monitoring when there have been interruptions, it is foreseeable that within a relatively short period of time her immune system would be seriously compromised and she would be exposed to the risk of death.

 

The Court had to weigh up what would be in her best interests

 

  1. In circumstances where AB is incapacitated, I have to make a decision on her behalf as to what is in her best interests. I have to consider a number of matters of a very obvious nature under Section 4 of the Mental Capacity Act 2005, but by virtue of subsection (6)(a), I have to consider her past and present wishes and feelings.
  2. As far as her past feelings are concerned, up to 2008, which is when we know that she did have capacity, her conduct in that period demonstrates that her wishes were to receive HIV treatment.
  3. As far as her present wishes are concerned, there is no dispute: they are very strongly opposed to HIV treatment.
  4. Parliament has decreed that I must go on to consider not only actual wishes and feelings but hypothetical wishes and feelings, because by virtue of Section 4(6)(b) I have to consider the beliefs and values that would be likely to influence her decision if she had capacity and I am also required by virtue of paragraph (c) to consider the other factors that she would be likely to consider if she were able to do so.
  5. I am perfectly satisfied, having regard to her willing and consensual participation in treatment up to 2008, that if she had capacity (and I would interpolate parenthetically that of course if she had capacity we would not be having this case), she would unquestionably enthusiastically embrace anti-retroviral treatment, which I do not shrink from describing as a miracle treatment.
  6. The authorities are clear that wishes and feelings are important and that they must be fully taken into account, even when the party is seriously incapacitated. It is wrong, on the authorities, for this Court to conclude that because someone is seriously incapacitated their wishes and feelings are irrelevant.
  7. On the other hand, the crucial consideration that I have to have in mind is the extent to which AB’s wishes and feelings, if given effect, can properly be accommodated within the Court’s overall assessment of what is in her best interests.
  8. Like so many aspects of litigation, the test all depends upon the particular facts that the Court is presented with, and on the particular facts that I am presented with, I have no hesitation in concluding that virtually no weight should be given to AB’s present wishes and feelings. Instead, I should place considerable weight on her past wishes, as demonstrated by the evidence, and on her hypothetical wishes, which I have no doubt would be in favour of the treatment.
  9. It is, it might seem, a strong step for the Court to take: to authorise a course of medication that involves deception, and I hesitate from saying that perhaps it is not so surprising in this post-truth world in which we now seem to live, but that would be perhaps a cynical aside. However, on the facts of this case, there can be no doubt that there has to be authorised a course of action that ensures that AB, in her best interests, receives the treatment that will likely save her. It is for this reason that I am happy to approve the order that has been put before me.
  10. The order will provide, however, that if the truth emerges to AB and she moves to a position of active resistance then the matter will have to be reviewed, and the Court will have to consider, in that situation, whether to move to forced administration of these drugs, which would be a very difficult decision to make, because it would not be a one-off administration of treatment, but would be a quotidian administration of treatment, which is a very different state of affairs to that which is normally encountered in this Court.
  11. For the reasons I have given I am wholly satisfied that the treatment proposed and the means of administration are plainly in the best interests of AB and it is so authorised.

 

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What IS the Court of Protection?

This is intended to be a beginner’s guide to the Court of Protection, not exclusively intended for lawyers. There are, in fact, some journalists who might benefit from it.  You may have been reading about the Italian woman who underwent a ceasarean section without her consent, and want to know how decisions like this are supposed to be made and what powers the Courts have.

To be fair to the national press, I’ve just had to expand 3000 words to absolutely race through even the basics of the Court of Protection, without even getting into the nuts and bolts of this case, so one can see why they end up saying “A secret Court” and leave it at that.   Perhaps in future, this piece might be a handy link or source for anyone who wants to understand the basics of  how that secret court is meant to operate.

I in no sense think that the Court of Protection is flawless or perfect, and it is perfectly possible for very bad decisions to be made, but at least understanding the nuts and bolts of the fact that decisions are made by a Judge, with a lot of tests and guidance might help people avoid some of the more dreadful factual errors that came about with some of the recent reporting. Otherwise you end up endlessly debating the rights and wrongs of a set of abhorrent things that DIDN’T actually happen, as opposed to very real and important rights and wrongs of a set of very troubling things that DID.

[It is like determining US and UK foreign policy post 9-11 based on Kay Burley’s account on Sky News on the day that “The entire Eastern Seaboard of the United States has been decimated by terrorist attacks” rather than what actually happened, which was awful and significant enough without lurid inaccuracies *]

What is the Court of Protection, and is is a secret court?

The Court of Protection is a branch of the English and Welsh court system, dealing with cases involving people who either do not have capacity to make decisions about certain things for themselves, or to determine whether in fact they do have that capacity. The Court of Protection as we now know it was set up by the Mental Capacity Act 2005, building on the Court of Protection which had previously dealt with financial matters  (Thanks to @barbararich for pointing out my original inacuracy, now fixed, and for doing so nicely).

It is not open to the public. The Press have to make an application if they want to attend the hearing. Some decisions of the Court of Protection (judgments) are made public on law sites like Bailii

http://www.bailii.org/ew/cases/EWHC/COP/

if they contain important points of law or principles which might apply to other cases or are in the public interest, but the day to day decisions are not made public  (yet – the President of the Family Division has indicated that he intends to bring about publication as a matter of course of all decisions of the family courts and probably the Court of Protection too).  When those decisions are made public, the identity of the person concerned is usually anonymised.   (There are certain, though rare cases, where the identity is revealed, such as the Mark Nearey case http://www.independent.co.uk/news/people/profiles/mark-neary-they-didnt-understand-steven-they-saw-me-as-a-fly-in-the-ointment-2295565.html )

So the Court of Protection is certainly secretive – there are arguments that this is done to protect the vulnerable people concerned, but the President of the Family Division takes the view that the counter argument that without exposing their decisions to public scrutiny there’s a risk that the public lose confidence in the work they do and that hyperbolae is taken as gospel  (he would seem, from events this week, to be right) and it is almost irresistable now that judgments from the Court of Protection will be made routinely available, and probably that the Press attendance at Court of Protection hearings will become the default position (with the Court having to given reasons why they SHOULDN’T be there)

Why did the Court of Protection come about?

It was introduced by the UK Parliament as a result of a case that went to the European Court of Human Rights, involving a man who is known as “L”  (the case is also well known as the “Bournwood” case, after the Trust involved). L had been a day patient at a centre, and lived normally with a family. He did not have capacity to make decisions for himself, but was not mentally ill or dangerous. One day he had an episode at the centre and when his family came to collect him, they were told that he had to stay at the centre. Now, if L had been detained under the Mental Health Act, his family would have had all sorts of legal safeguards and abilities to challenge his detention. Equally, if L had had the capacity to say to the unit “I want to go home” they would have had to let him, but L fell between these two situations, and there was no proper mechanism. Many commenters and professionals working with vulnerable adults felt that it was inherently wrong that someone like L could be detained for months or years with no legal safeguards, just because he wasn’t in a position to object. The ECHR agreed.

At the same time, Parliament brought into one statute, legal provisions for some decisions that the High Court had historically made under their Inherent Jurisdiction  (Inherent Jurisdiction would require a whole other beginners guide, but if you just read Inherent Jurisdiction as “High Court superpowers” you won’t go far wrong) – for example deciding whether doctors could carry out surgery on a patient who was refusing it, dealing with marriages where people had no ability to understand the marriage vows, protecting the finances of vulnerable people, and wrapped it all up into one statute.

The thinking was to give protection and safeguards for the most vulnerable people in society, those who are not able to look out for their own interests.  (Many commenters believe that the MCA began with those noble intentions but hasn’t in practice delivered on them)

Who brings cases to the Court of Protection ?

The cases are normally brought by one of these four groups (though others are possible) : –  the health trust whose doctors are treating the person, the care home who is providing care for the person, the Local Authority who are providing services for the person, or on behalf of the person or their family.

How does the Court decide whether a person has capacity?

The Mental Capacity Act sets out a test as to the REASON why the person lacks capacity

Section 2

(1)For the purposes of this Act, a person lacks capacity in relation to a matter if at the material time he is unable to make a decision for himself in relation to the matter because of an impairment of, or a disturbance in the functioning of, the mind or brain.

(2)It does not matter whether the impairment or disturbance is permanent or temporary.

And then sets out a test for deciding WHETHER  a person lacks capacity

Section 3 Inability to make decisions

(1)For the purposes of section 2, a person is unable to make a decision for himself if he is unable—

(a)to understand the information relevant to the decision,

(b)to retain that information,

(c)to use or weigh that information as part of the process of making the decision, or

(d)to communicate his decision (whether by talking, using sign language or any other means).

(2)A person is not to be regarded as unable to understand the information relevant to a decision if he is able to understand an explanation of it given to him in a way that is appropriate to his circumstances (using simple language, visual aids or any other means).

(3)The fact that a person is able to retain the information relevant to a decision for a short period only does not prevent him from being regarded as able to make the decision.

(4)The information relevant to a decision includes information about the reasonably foreseeable consequences of—

(a)deciding one way or another, or

(b)failing to make the decision.

It is VERY VERY important to note that a person is entitled in law to make a bad decision, an unwise decision, a daft decision, a decision that no other person would take; AS LONG as they understand the situation they are making the decision about.   (For example, Carla out of Corrie is entitled to marry Peter Barlow even though he is a love-rat with a history of bigamy, an alcoholic and is trying it on with Tina from the Rovers, even though many people would think she was foolish to do so. But if she does not understand that marriage is the union of one man and one woman (currently) and is intended to be for life although it can be ended through divorce, then she can’t marry him.  Just as, if he drinks and is so intoxicated that he can’t understand that, he can’t legally enter into a marriage contract  – but that is PRETTY drunk)

It is also important to note that just because a person lacks capacity to make one particular decision, it doesn’t mean that they lack capacity to make any sort of decision. Some decisions are more complicated to weigh up than others and need more capacity to understand.  Over a period of time, the Court of Protection has decided cases and set up guidelines for what sort of understanding a person has to have for certain decisions.

For example, classically, in order for a person to have the capacity to consent to sexual intercourse they have to be able to understand the following three things :-

(i) The physical mechanical act

(ii) That pregnancy can occur and what pregnancy is  (and contraception)

(iii) that you can get diseases through sex (and how to avoid that)

The person doesn’t have to understand the emotional implications (that you could get heart-broken or sad, or that the other person might) or be able to weigh up who is a good person to have sex with and who is not, just those three factors.    (For homosexual sex, the second factor is taken out)

You will see from the legal test that the person has to be helped, with explanations suitable for them, to reach the point of understanding the issues so that they can make the decision for themselves. The law WANTS people to make the decision for themselves, and it is also worth noting that the starting point is that every person HAS capacity unless evidence is provided to the contrary.

If the Court decide that a person lacks capacity, what then?

The Court then have to make what is called a “best interests” decision.  That means deciding what is in the best interests of the person. That might be what the State (the doctors or social workers) say is best, it might be what the person themselves is saying or showing that they want, or it might be something else entirely.

The legal test is set out in the Mental Capacity Act

section 4 Best interests

(1)In determining for the purposes of this Act what is in a person’s best interests, the person making the determination must not make it merely on the basis of—

(a)the person’s age or appearance, or

(b)a condition of his, or an aspect of his behaviour, which might lead others to make unjustified assumptions about what might be in his best interests.

(2)The person making the determination must consider all the relevant circumstances and, in particular, take the following steps.

(3)He must consider—

(a)whether it is likely that the person will at some time have capacity in relation to the matter in question, and

(b)if it appears likely that he will, when that is likely to be.

(4)He must, so far as reasonably practicable, permit and encourage the person to participate, or to improve his ability to participate, as fully as possible in any act done for him and any decision affecting him.

(5)Where the determination relates to life-sustaining treatment he must not, in considering whether the treatment is in the best interests of the person concerned, be motivated by a desire to bring about his death.

(6)He must consider, so far as is reasonably ascertainable—

(a)the person’s past and present wishes and feelings (and, in particular, any relevant written statement made by him when he had capacity),

(b)the beliefs and values that would be likely to influence his decision if he had capacity, and

(c)the other factors that he would be likely to consider if he were able to do so.

(7)He must take into account, if it is practicable and appropriate to consult them, the views of—

(a)anyone named by the person as someone to be consulted on the matter in question or on matters of that kind,

(b)anyone engaged in caring for the person or interested in his welfare,

(c)any donee of a lasting power of attorney granted by the person, and

(d)any deputy appointed for the person by the court,

as to what would be in the person’s best interests and, in particular, as to the matters mentioned in subsection (6).

(8)The duties imposed by subsections (1) to (7) also apply in relation to the exercise of any powers which—

(a)are exercisable under a lasting power of attorney, or

(b)are exercisable by a person under this Act where he reasonably believes that another person lacks capacity.

(9)In the case of an act done, or a decision made, by a person other than the court, there is sufficient compliance with this section if (having complied with the requirements of subsections (1) to (7)) he reasonably believes that what he does or decides is in the best interests of the person concerned.

(10)“Life-sustaining treatment” means treatment which in the view of a person providing health care for the person concerned is necessary to sustain life.

(11)“Relevant circumstances” are those—

(a)of which the person making the determination is aware, and

(b)which it would be reasonable to regard as relevant.

You can see that the Court are obliged to consider and take into account all that is known about what the person themselves wants, or would want, or has previously expressed about wanting (remember that a person might only temporarily lack capacity, so the Court have to take account of anything the person said or showed about the issue in the past), and also has to take into account the views of anyone who cares for the person or is interested in their welfare.

This is the difficult bit, and in most Court of Protection cases, the majority of the judgment is spent on the Judge deciding what is in the ‘best interests’ of the patient to do.  Sometimes that accords with what the patient is saying or showing they want, sometimes it does not.  It is the hardest part of the exercise, and to an extent, I agree with Lucy Series from The Small Places blog about capacity and mental health :-

A recently ratified UN treaty – the Convention on the Rights of Persons with Disabilities – poses the question: why should people with disabilities and mental illnesses face these kinds of interventions when people without do not? It looks very much as if the Mental Capacity Act itself is not compatible with this Convention, although views on this differ. It is certainly a question it would be good to see the media asking more often… Again, this is an issue that comes up a lot around the Mental Capacity Act 2005: how can we distinguish decisions which are merely irrational or unwise, which everybody is entitled to make, from those which are incapable. This is actually quite a profound philosophical problem (my own view is that it is insoluble; ‘mental incapacity’ is a conceptual device which we cling onto to mask the value judgments we are bringing to bear when justifying interventions in situations which we regard as intolerable). The disability Convention referred to above poses serious questions about how we deal with ‘capacity’, and emphasises the role of support for decision making. Even the Mental Capacity Act requires support to be provided for a person to make their own decision before it is made on their behalf, and decisions made on their behalf should involve the person as far as possible. “

How does the Court ensure that it is making the decision that is right for the person, and not the decision that “seems” the right thing to do from a paternalistic “The State knows best” approach.  The Court of Protection at essence is a referee between the tension of “the State needs to decide what is best for vulnerable people” and “people should be free of State interference and make their own decisions”.  It is not easy, and it can seem to those outside that the Court of Protection doesn’t always get things right.

It is certainly a new system (in terms of law, 8 years of operation is a baby) and it would be astonishing if mistakes weren’t being made and lessons were there to be learned. So it is important to scrutinise the decisions and for the Court of Protection to be responsive and reflective to changes both in law and attitudes in society. Twenty years ago, a man saying that he intended to marry another man would have seemed peculiar to most of society, now a Conservative Prime Minister is driving that change.

But, if a person doesn’t have capacity to make a decision, how do they fight the case?

Well, this is the million dollar question. Remember firstly that just because a person lacks capacity to make one decision doesn’t mean that they lack capacity to make all decisions. So it is possible for a person to be able to instruct his lawyers to fight the case, whilst the Court decides on the real issue in question. But very often the issue of capacity will also affect the person’s capacity to instruct a solicitor.  There is firm guidance on the legal test to be able to instruct a solicitor, and where a person doesn’t meet that test, they can’t give instructions directly to a solicitor.

[A person who HAS capacity is able to tell their solicitor to do something really foolish or unwise or downright dumb – i.e Carla can tell her solicitor to put all of her assets in Peter Barlow’s sole name and to sign a pre-nup saying that she has no claim on any of what is now his property. That’s stupid, but if she understands the nature of what she is doing, she can do it.]

What happens ordinarily then is that an agency known as the Official Solicitor is appointed by the Court   (not by the social worker or Trust, as certain national newspapers seem to think) and the Official Solicitor will decide how the case is to be run on the persons behalf  – that might be to fight the case every inch of the way, it might be to offer no resistance, it might be to be neutral and say that the doctors or social workers have to prove their case, or it might be that some parts of the case are challenged very hard and others aren’t. It is up to the Official Solicitor)

Now, one can see where that causes a problem. The person lacks capacity, say, to make an informed decision that if surgeons don’t cut off their foot they will die of gangrene, but is very vocally saying “Don’t cut off my foot, I would rather die”.   The doctors will be able to tell their lawyers to argue all the reasons why the surgery will happen. The Judge knows what the person is saying and has to take it into account. But there could very well be no lawyer who actually argues to the Court all of the reasons why the surgery SHOULDN’T happen, they will only do that if the Official Solicitor decides that it is in the person’s best interests to fight the case.

(You may see that you end up with both the Official Solicitor and the Court making decisions about what each of them CONCLUDES is in the person’s best interests to do and that can appear to be a blurring of roles.  When a lawyer acts for someone who has capacity, she gives them ADVICE about what is in their best interests, often very strong advice, but where a person says “I hear all that, but I still want to do X instead” that lawyer goes into Court and argues fearlessly and without favour for X.  You end up with, here, a situation where the most vulnerable people in society get less protection from the lawyer charged with representing them, than they would if they had capacity)

If you want to know more about the decision of the Court of Protection in ceasarean section cases, I heartily recommend this piece , which focuses on the legal side and the tests to be met

http://thesmallplaces.blogspot.co.uk/2013/12/more-questions-than-answers-on-forced.html#more

and this piece

http://www.birthrights.org.uk/2013/12/views-on-the-forced-cesarean-judgment/

Which looks at it from the perspective of the pregnant mother

* She actually did say that. And what better reason do I need to crowbar in a “Who said this, Kay Burley or Ron Burgundy” quiz?

http://www.huffingtonpost.co.uk/2012/03/29/anchorman-2-ron-burgundy-kay-burley-quiz_n_1387332.html

Stay classy, internet

Removal of a vulnerable adult from his home

The decision of the Court of Protection in Re A Local Authority v WMA 2013

http://www.bailii.org/ew/cases/EWHC/COP/2013/2580.html

This is not, I think, a development in the law, but it is a recent decision by the Court of Protection which authorised the removal of a vulnerable adult WMA from his home, authorised the LA to go into his home and remove him, authorised him to be placed somewhere he didn’t want to go, authorised a deprivation of his liberty and authorised if necessary the police to go into his home and remove WMA, all on the basis that this was in his best interests, WMA lacking capacity to make such decisions for himself.   It therefore raises interesting talking points.

What orders are necessary? I find that these are: a power for the local authority to enter the home if necessary; a power to the police to restrain WMA if necessary; an order that WMA be removed from his current home and taken to B where the local authority will have power to retain him if needs be; and the local authority will have the power, of course, in addition, to sign the tenancy agreement on his behalf. These measures are proportionate and necessary.

As such, it is a powerful reminder of the powers that the Court of Protection have; the impact such powers can have on vulnerable individuals and additionally a useful summary of the factors to be balanced and tests to be applied.

I have to say that my own take on the case (which is not that important, but I’ll give it) is that I felt WMA’s wishes were somewhat marginalised and that the case was substantially more finely balanced than it might appear from reading the judgment. I probably would have authorised WMA’s removal, if all efforts to improve things for him at home had failed, but I would have found it more difficult to do so.

  1. The case concerns the future of a twenty five year old man, WMA, and where he should live plus what help should be given to him. It raises complex issues about best interests and deprivation of liberty.
  1. WMA suffers from an autistic spectrum disorder. Although it is possible to have a conversation with him about his clearly expressed views, it is plain, and agreed by even his mother MA, that he lacks capacity in some important aspects to which I shall come. He has been diagnosed in these proceedings as having atypical autism and a pervasive development disorder. He presents with unpredictable behaviour on occasion.
  1. He leads an isolated and insular life with MA, who has also sight and mobility problems of her own. The local authority is concerned about the impact of isolation on WMA’s long term development and its social work team has reluctantly come to the conclusion that he needs to be moved into supported living accommodation, despite the difficulty of the initial move, because in the long term this will help WMA and MA to develop a more healthy relationship. It is argued that there is currently an unhealthy degree of interdependence. The local authority alleges too that MA is unable to care for WMA properly, she is likely to be harming his development and it is against his best interests to remain with her.

 

 

Part of the problem in the case was that although WMA wanted to be with his mother, MA; professionals felt that MA was (a) holding him back and impairing the progress and development that he could make and (b) not able to actually care for him, to the point where the home conditions were described as both ‘squalid’ and the sort of home conditions that would lead a child to be removed for neglect.  MA did herself no favours by the way she participated in the hearing, one has to say.

The LA put the case like this

 

  1. 67.   “It is my professional view that WMA is a twenty three year old man with the potential to lead a more fulfilling life. I am also of the view that MA is not deliberately abusive to him but rather has needs of her own that have not been assessed but which impact upon her ability to care for WMA effectively and to manage her own living environment. I think she is not aware that her behaviour towards him is abusive. She has little expectations of him and there is evidence of the frustration she experiences from undertaking his care, shouting at him, preventing him from leaving the property. MA has stated on many occasions she does not want local authority involvement with the family, blaming them for the lack of diagnosis of WMA as a child. She has been found to be neglectful through safeguarding adults procedures. I am concerned that WMA has been treated in an inhumane and degrading manner by MA and that his true potential has been unrecognised and stifled. In order for him to live safely and towards a more fulfilling life I think he should move on to supported accommodation whilst continuing to have contact with his mother.”

The first issue in the case, where WMA had capacity to make decisions for himself, was fairly straightforward. (I did note with some surprise that WMA’s IQ was assessed at being 64, rather higher than one might have believed reading some of the descriptions of him, but of course with autistic spectrum disorder IQ itself isn’t the only measure of capacity)

  1. WMA’s significantly learning disability as a result of his autism meet the criteria of section 2 for he has an impairment of functioning of the mind or brain. Dr. Carpenter has made this quite clear. Even MA has doubts as to his capacity and considers him less capable than others of achieving in this life.
  1. In addition, WMA clearly meets the functional tests in section 3. He cannot use all relevant information relevant to a decision as part of the process of making a decision. This test is decision specific but I am satisfied that WMA cannot make decisions as to his residence, his care plan and his contact with his mother. Of course, WMA has sufficient capacity to decide what he wants to eat but he cannot cope with concepts or make sensible plans as to where to live. In addition, he cannot cope with or even contemplate change, save with assistance.
  1. This, too, is confirmed by Dr. Carpenter who made it clear to me that this is not a borderline case as to capacity. He counselled against believing that WMA has near capacity simply because of his verbal abilities. That view of the functional test was echoed in the evidence of Mr. McKinstrie, the independent social worker, and the views of the social workers who gave evidence.
  1. Accordingly, I have concluded WMA cannot use or weigh the factors as to where he should live. His view that he should remain living with his mother is a decision he is incapable of making. He cannot weigh up all the considerations. Alongside that fundamental issue he cannot decide what care package is suitable for him or, indeed, what contact if away from MA he should have with her.

Having established that WMA lacked capacity, the Court then had to go on to consider what was in his best interests, taking into account all of the factors set out in the Mental Capacity Act 2005.

The Court made the following factual findings

  1. I make the following findings.
  1. First, the local authority social workers have been unable and will be unable to provide appropriate care for WMA and monitor it because of his refusal to accept it and because of MA’s inconsistence and erratic interference with the local authority help.
  1. Second, there is a worrying history about MA’s care for WMA that shows no sign of abating.
  1. Third, that the local authority has made special efforts over the last eighteen months to engage fully with both of them but there has been an unacceptable degree of conflict. I am not persuaded the local authority could have done any more and I have noted with concern the helpful evidence of CG that she has felt under threat recently.
  1. Fourthly, WMA lives an isolated lifestyle and is expected often to be in mother’s eyes and ears. His relationship with her, however, is a frustrated one and there is clear evidence on mother’s case alone that he is, at times, beyond control.
  1. Fifthly, the isolation is such that WMA just does not go out with any with any regularity. Dog walking and shopping appear to be virtually the limit of his outdoor activities with the exception of the few outings that were organised by Delos who he now rejects. As long ago as February 2012 he could not recall when he last went out anywhere.
  1. Sixthly, the home of MA and WMA continues to be kept to a very low standard of cleanliness and, whilst it is not for the court to impose respectable middle class standards of care, nonetheless, the home’s condition has on occasion deteriorated. The recent evidence of CG, for example, that the fridge is kept to a low standard of cleanliness is very concerning. True enough, this has not yet made WMA ill but I am sure that it will one day,
  1. Seventhly, there is a plain history of neglect of WMA by his mother. She does not keep him sufficiently safe or clean or his clothes sufficiently clean to an acceptable standard. The clear point is that MA’s standards are not simply lower than the norm, they are below a good enough standard.

It is important to note that the ‘safeguarding concerns’ were not the test – they were a factor to be weighed in the best interests decision, but it was not a simple matter, as the Official Solicitor suggested the LA had put it of safeguarding concerns being the focus of the Court.  The Official Solicitor also raised on behalf of WMA that the case might well be social engineering. It was not right to move WMA simply because he might DO BETTER in a setting away from his mother   (this is a well-established principle in care proceedings), it had to be a decision taken in the round, for his best interests.

There was an interesting debate about what the starting-point is in such cases (i.e does one START with the position that WMA ought to be at home where he wants to be, or START with a blank sheet of paper?  In care proceedings, of course, the Court STARTS with the proposition that it is better for a child to be at home with his parents and has to have compelling evidence to move away from that proposition)

Not so in Court of Protection cases.

  1. I quote from another part of the K v LBX case [2012] EWCA (Civ) 79 not cited by Mr. O’Brien. In discussing whether or not the court would start from placing the person concerned with their family, Black LJ said this:

“A prescribed starting point risks deflecting the decision maker’s attention from one aspect of Article 8, private life, by focusing his attention on another, family life. In its wider form incorporating reference to both private and family life, there is a danger it contains within it an inherent conflict for elements of private life, such as the right to personal development and the right to establish relationships with other human beings in the outside world may not always be entirely compatible with the existing family life in the sense of continuing to live within the existing family home.”

It is a difficult tension here – once a person lacks capacity, there is no “Threshold criteria” no test of harm that has to be crossed by the State to justify their removal from their family home; the Court just has to consider whether it would be in WMA’s best interests to be so moved.

Of course, the law is intended to protect vulnerable people who prior to the MCA 2005 would have been left alone to live in squalid conditions with their needs not being met unless the person met the criteria under the Mental Health Act for detention or Guardianship (or the little-used powers under community care legislation)

National Assistance Act 1948

s47 Removal to suitable premises of persons in need of care and attention.

(1)The following provisions of this section shall have effect for the purposes of securing the necessary care and attention for persons who—

(a)are suffering from grave chronic disease or, being aged, infirm or physically incapacitated, are living in insanitary conditions, and

(b)are unable to devote to themselves, and are not receiving from other persons, proper care and attention.

 

Which made provision for an application to be made to Court and an order authorising the removal.  I’m not sure how often that was ever used, but one can see that there is something of a test in there (and a pretty high one), rather than the generic principle now that a person lacking capacity can be removed from their family if the Court of Protection consider it is in their best interests.

There are no police powers to remove a vulnerable adult from a home where they are felt to be at risk, and the criminal offence of neglecting a vulnerable adult whom you are caring for only came about with s44 of the Mental Capacity Act 2005.

On the other hand, this leaves a vulnerable group of adults, those lacking capacity, as being those for whom the Court of Protection can make wide-ranging decisions about what is in their best interests. One hopes, of course, that the Court of Protection makes what one would objectively consider to be in the best interests of the vulnerable adult, but there is this obvious tension between what the State might consider to be in the best interests of the adult, and what the adult and their friends and family might consider to be in the adults best interests.

The Mental Capacity Act of course came about to fill a gap in the law, the “Bournewood gap” where a person who lacked capacity to declare that they wanted to leave a residential unit ended up remaining there with his carers being unable to challenge that decision or remove him, and the case had to go all the way to Europe.

We are still in relatively early days of the Court of Protection and the working of the MCA in practice, but a case like this does point up how even when a Judge carefully analyses and balances all of the competing factors, the exercise of a “best interests” decision can completely turn WMA’s life upside down, and unless his capacity to make decisions changes, such a decision will be very hard to reverse or challenge for WMA in the future.

It could be argued, and is being by many who come across the MCA, that the solution is becoming worse than the problem. It is very hard not to be paternalistic when operating the best interests decision.  (for me, in this one, the chronic neglect and home conditions probably just tip the balance, when combined with the long-standing unsuccessful attempts to resolve this, but if they do tip the balance, it is only just, and I might well have gone on to find that the article 8 right to private and family life trumped it).  It does seem to me a little odd that there’s no presumption in the MCA that the vulnerable person’s family are better placed to make a decision for what is in their best interests unless there are compelling reasons to the contrary.