Key Facts
- •North Bristol NHS Trust applied for declarations that R lacks capacity to decide on a pre-term Cesarean section for her unborn baby and that the procedure is in her best interests.
- •R, a 32-year-old serving prisoner, did not object to a Cesarean section but had intermittently refused fetal monitoring.
- •Conflicting capacity assessments were conducted; one found R capable, others found her incapable.
- •Medical evidence indicated progressive placental dysfunction, posing a significant risk of fetal death or brain damage.
- •R's psychiatric presentation was described as "perplexing" and possibly linked to cognitive impairment or neurodevelopmental issues.
- •The court considered whether a formal diagnosis of learning disability was necessary to establish incapacity.
- •The court assessed R's best interests, considering physical and psychological well-being, the risk of delivering a stillborn baby, and R's limited expressed views.
Legal Principles
A capacitous individual can decide on medical treatment.
Mental Capacity Act 2005
Capacity is decision-specific, assessed at the time the decision needs to be made.
Mental Capacity Act 2005 ss 1-3, Kings College Hospital NHS Foundation Trust v C and V [2015] EWCOP 80
All practicable steps to help a person make a decision must be taken before concluding incapacity.
Mental Capacity Act 2005 s. 1(3)
An unwise decision doesn't automatically mean lack of capacity.
Mental Capacity Act 2005, Heart of England NHS Foundation Trust v JB [2014] EWHC 342 (COP)
Lack of capacity requires an impairment or disturbance in the functioning of the mind or brain causing inability to make a decision.
Mental Capacity Act 2005 s. 2(1), A Local Authority v JB [2022] AC 1322
A formal diagnosis isn't always required to establish an impairment of the mind or brain.
Mental Capacity Act 2005 s. 2(1), Pennine Acute Hospitals Trust v TM [2021] COPLR 472
Best interests must consider all relevant circumstances, including past and present wishes, beliefs, values, and views of carers.
Mental Capacity Act 2005 s. 4, Aintree University Hospitals NHS Foundation Trust v James & Ors [2014] AC 591
Even if lacking capacity, a person retains human rights, including Articles 2, 3, and 8 of the ECHR.
P v Cheshire West [2014] UKSC, ECHR Articles 2, 3, 8
Outcomes
R lacks capacity to decide on a pre-term Cesarean section.
R's inability to understand, retain, use, and weigh relevant information regarding the procedure, due to cognitive impairment and past trauma, prevents her from making a capacitous decision.
It is lawful for the Trust to perform an elective Cesarean section on R.
The procedure is deemed to be in R's best interests, primarily to avoid the significant psychological trauma of delivering a stillborn baby, despite the Cesarean not being medically necessary for R's physical well-being.