“Proposal 1 - continued voluntary admission where [CC] attends for inadequatenutritional support via the PEG tube and that a Mental Health Act is not pursued even if she is atimmediate risk. They outline the potential advantages and disadvantages of this proposal. Proposal 2 – admission under Section 3 of the Mental Health Act in order to offer PEG feed meal plan onthe ward and potassium replacement against her wishes. Again they outline the potential advantagesand disadvantages of this proposal. Proposal 3 – to employ an agency nurse in outpatients to support [CC’s Mother] to administer PEG feed.This would be a Monday to Friday arrangement whereby a nurse could administer the PEG feed in thecommunity. Proposal 4 – CC will attend the outpatients three times a week for support from the outpatientnursing team to administer the PEG feed. Again they outline the advantages and disadvantages of thisproposal. Proposal 5 – referral for weight restoration treatment under intensive care including generalanaesthesia. They outlined the potential for new trauma during this treatment, as well as risks ofgeneral anaesthesia at this low BMI. They also outline the potential consequences of sudden weightgain.”
“‘a doctor cannot lawfully operate on adult patients of sound mind, or give them any other treatment involving the application of physical force ... without their consent’, and if he were to do so, he would commit the tort of trespass to the person. [55]”
“… the principle of self-determination requires that respect must be given to the wishes of the patient, so that if an adult patient of sound mind refuses, however unreasonably, to consent to treatment or care by which his life would or might be prolonged, the doctors responsible for his care must give effect to his wishes, even though they do not consider it to be in his best interests to do so.”
“Even when his or her own life depends on receiving medical treatment, an adult of sound mind is entitled to refuse it.”
“There is no doubt that this principle applies in the context of choosing whether to refuse food and drink (see, for example, Secretary of State for the Health Department v. Rob[1995] 1 All ER 677 and A Local Authority v. E and Others.[2012] EWHC 1639 ). Thus, if Dr. A. has the capacity to make decisions as to whether to take food and drink, he is entitled to starve himself to death if he so chooses. The question is: does he have the capacity?”
“it is not uncommon for people to go on hunger strike in the hope that the Government will be forced to change its policy. Hunger strikes are a legitimate form of political protest. Not all hunger strikers are suffering from a mental disorder ….”
“The determination of capacity under MCA 2005, Part 1 is decision specific…. all decisions, whatever their nature, fall to be evaluated within the straightforward and clear structure of MCA 2005, ss 1 to 3 which requires the court to have regard to 'a matter' requiring 'a decision'. There is neither need nor justification for the plain words of the statute to be embellished.”
“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.” (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). (a) deciding one way or another, or (b) failing to make the decision.”
“Information about decisions the person has made based on a lack of understanding of risks or inability to weigh up the information can form part of a capacity assessment – particularly if someone repeatedly makes decisions that put them at risk or result in harm to them or someone else.”
“in assessing the question of capacity, the court must consider all the relevant evidence. Clearly, the opinion of an independently instructed expert will be likely to be of very considerable importance, but in many cases the evidence of other clinicians and professionals who have experience of treating and working with P will be just as important and in some cases more important. In assessing that evidence, the court must be aware of the difficulties which may arise as a result of the close professional relationship between the clinicians treating, and the key professionals working with, P ….”
“4.3 She told me that high school was worse. 'They came down too hard on me. I didn’t like the rules. They invented punishments. I’d get punished at school. Then my parents would grill me. I couldn’t communicate, it was torture. It was bad enough having trouble at school, then at home. I didn’t want to talk, it was just a blockage.’ She told me that she was never scared of the punishment, rules or possibility of being expelled. 'I was dressing the part, doing the part with all the Judaism. I was wondering when it would all blow up. It had to.’ She told me that she was never able to concentrate in school, 'because I was clever, everything was overlooked. I was bored. I never wrote notes. I couldn’t concentrate for more than two seconds.’”
“ 4.4 She described episodes of not eating in high school. She would stop eating for a few days. 'I got very overwhelmed, new places, new people.͛ She described a school weekend away in year 1Ϭ. 'It took a long time to get there. I was on a high, very energetic, having fun, I was being mischievous, getting into trouble. Then I crashed, down and down, I stopped eating and drinking. I was low in mood, stayed in bed. They took me to hospital.’ She then returned home and began eating again. She said the same thing happened at the end of Year 10 when in Camp America. A similar episode occurred in year 11 whilst at home. She denied that she felt any sense of power during these episodes, not as a way of eliciting care and nurturing. There was no sense of achievement. 'No, it was just something that was happening, from year ϵ I was getting really depressed.’ 4.5 She was sent to College … at 16. 'There weren’t many choices in my community. I didn’t want to go, I didn’t have a choice, but I didn’t know what I wanted either.’ She said that she stayed in bed for a lot of the time. Due to COVID, she was sent home, 'It was perfect, I never had to go back.’”
“4.6 She had volunteered with children with special needs which she enjoyed. She began working in this role around 2020/2021. She recalled that in Summer of 2021 she was working on a camp and felt quite depressed. She recalled that her eating was still an issue, in that she was not eating adequately, but was clear it was not weight related. She described having ‘disordered eating.’ On further questioning, she told me that she was not eating enough, that she stayed in bed not eating, that she would start eating very late at night and would only have one meal a day. She denied that she was worried about weight at this stage. She said 'I was very unhappy; it was my only way of expressing it. I guess some of it was about control. I was weighing myself often, but it was more about....not cause of how I looked.’ 4.7 She explained that there was still 'plenty of stuff I was being forced to do. I still didn’t even have a smartphone. I was told off for not praying, too short skirts. I was being controlled big-time.’ 4.8 She took an overdose of painkillers during the week she was admitted to [Hospital] in October 2021. She did not tell anyone. She stopped speaking. When asked what drove this, she said 'I shut down. I wanted to die. I stopped eating and drinking. I had nothing to say to them. I was angry. I felt misunderstood in general. I was never able to communicate.’ 4.9 She told me that she was sectioned under the Mental Health Act (MHA) as she was mute and not making eye-contact. She was transferred to a psychiatric ward for five weeks. 'I wasn’t eating and drinking, my brain wasn’t functioning. My BMs were dropping. They stuffed Glucogel in my mouth, held me down. I didn’t know what was happening. The other patients were scary. It was a traumatic time.’ She talked about being held down to give fortisip and suffering with refeeding syndrome. 4.10 She was then transferred to [the Ward]. She described how she felt out of control. 'Change has always been hard for me. I didn’t know what was happening. I was self-harming, cutting for a while, cutting badly.’ She told me that she had been self-harming since she was young. When asked about the reasons for her self-harm, she said 'I don’t know, I just did it, I liked it, the pain, the blood, I liked it all.’”
“4.13 Initially, she refused to go to [Ward]. She told me she was kicking and screaming, crying and hysterical. She refused all treatment. 'They tubed me, they gave me glucagel.’ She told me that she was seeing visitors and going out with friends. She was asking friends to bring her food and drink that she was craving. But on the ward, she would not eat. She was only nourished through NG feeding and oral supplements. When challenged why this was the case, she replied, 'If I make a decision, I get stuck, so if I don’t want to eat, I won’t eat. Its always the same, an inability to flex.’ She talked about headbanging when she became overwhelmed. She was NG fed until the point where she was discharged. 'On the day I left, I was still restrained.’ 4.14 When I examined her cognitions around this time, she said 'I knew that they would give it to me anyway, either by supplement or NG. It wasn’t a fear of fatness, or a drive to be thin. I was obsessed with the numbers, it was a control of the numbers.’ She added that towards the end, she 'couldn’t care less about the weight.’ She told me that she was eating with friends and was not worried about the weight. She described coming home from hospital and having a pizza party which she instigated. She said that throughout all this, in the background, she still felt a religious pressure, and gave some examples, like when she was at home, she would have to wear a skirt, but when with friends, she wore leggings. 4.15 She was readmitted again soon after discharge. 'I didn’t know what was expected of me. I didn’t have a discharge meal plan. I was self-harming badly. My eating was disordered. I stopped eating again.’ She remembers that the 'straw that broke the camel's back' was when she gained weight in the community and weighed herself. She felt like she had 'lost control.’ 'It’s like I’m all or nothing. I was so unhappy in general. They pushed my weight up, but it didn’t solve my depression.’ 4.16 During the February to May 2022 admission, she described the situation getting a lot worse. 'The longer you spend on an [Eating Disorder] ward, the more you develop an ED.’ She told me that she continued to struggle with communication, and therefore struggled to engage with therapy and groups. 'Nothing was offered therapeutically, I didn’t like the one-to-one therapy, I still felt misunderstood.’”
“Given these factors, [CC] meets the diagnostic criteria for anorexia nervosa. To clarify, anorexia simply means lack of appetite with subsequent weight loss. Anorexia nervosa is a mental illness, as defined in ICD 11 and other diagnostic manuals.”
“[CC] is keen to try lithium, given its evidence in mood disorders and treatment resistant depression. However, her history of poor medication compliance, frequent vomiting and fluid restriction, with associated kidney injury as well a low BMI, make this option unsafe. If prescribed it would likely cause life limiting renal failure and / or acute toxicity which could lead to brain damage as well as cardiac arrhythmia, with high risk of a fatal outcome in the short and long term.”