This case involved capacity and the refusal of treatment. It was necessary for the Court to consider P’s independence and his best interests when making a decision.

Following a long history of schizophrenia, P sustained a severe injury and was reluctant to undergo treatment.

Recently, an application was made by the NHS Trust to assess whether P held the capacity to consent to surgery and if he lacks capacity in this matter, to consider whether the proposed surgery was in his best interests.

Background:

By way of background, P is a 42-year-old male who has been diagnosed with Paranoid Schizophrenia. On 27 October 2023, P was found unresponsive in the community; He had sustained multiple injuries and suffered from a seizure. Following this, the P was admitted to his local emergency department where it was determined that P had fractured his left humeral head and dislocated his left shoulder.

P had recently switched his medication, which was used to manage his schizophrenia, from clozapine to olanzapine, which may have deteriorated his condition. Some of the side effects of olanzapine include depression, unusual behaviour and restlessness; it is suggested that this could explain P’s deviant behaviour, such as hostility towards staff.

Paranoid Schizophrenia gives rise to irrational beliefs and delusions which impact the way in which a person interprets their surroundings. As P was diagnosed with Paranoid Schizophrenia, he experiences delusions, which lead him to believe that surgery was unnecessary as it would not prevent future pain. P also believed that he was unable to lose function in his arm and therefore, treatment was not required.

Legal Background:

Dr F is a consultant liaison psychiatrist who met with P on 9 November 2023 to conduct a capacity assessment. The aim of the capacity assessment was to determine whether P held capacity to consent to surgery.

A variety of concerns were raised by Dr F regarding the treatment of P’s schizophrenia; P had not attended follow-up appointments with his community group and there were concerns that he had not taken his antipsychotic medication. Following P’s admission to hospital, he met with the mental health team who identified that since October 2021, P’s condition had deteriorated severely. It was clear that P was unaware of his diagnosis as he declined medication for his paranoid schizophrenia; P also denied any mental ill-health. Therefore, Dr F concluded that P lacked the capacity to refuse the surgery he required, because of his delusions, he was unable to believe the medical rational.

Mr D, a consultant orthopaedic surgeon, described the surgery as the ‘best treatment’ for P’s consistent shoulder pain. Mr D also determined that P did not hold the capacity to refuse surgery. P’s brother and father supported this conclusion by advising Mr D that if P held capacity, he would want to have the surgery.

As P lacked the capacity to comprehend the surgery he required, he was unable to make a decision within the means of Section 3 of the Mental Capacity Act 2005 and subsequently, was unable to provide his consent, or refusal, to the surgery. He therefore lacked capacity in respect of the relevant matter, the giving of his consent for shoulder surgery. Thereafter, the NHS Trust sought a declaration that it was lawful to complete surgery on P’s shoulder and restore function to his arm.

Conclusion:

The Court of Protection ruled the application in favour of the NHS Trust. Despite all the practicable steps taken to assist P in making a capacitous decision, they were unsuccessful as P was unable to assess the benefits and the risks of the surgery he required.  

Subsequently, an Order dated 14 November 2023 was sought declaring that it was lawful to conduct the surgical procedure because it was within the P’s best interests.

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