Cambridge University Hospitals NHS Foundation Trust v GW (by Her Litigation Friend, The Official Solicitor
| Jurisdiction | England & Wales |
| Judge | Mrs Justice Theis,Mrs Justice Theis DBE |
| Judgment Date | 09 July 2021 |
| Neutral Citation | [2021] EWHC 2105 (Fam) |
| Docket Number | Case No: FD21P90060 |
| Court | Family Division |
[2021] EWHC 2105 (Fam)
IN THE HIGH COURT OF JUSTICE (FAMILY DIVISION)
IN THE MATTER OF THE INHERENT JURISDICTION
AND SECTION 8 OF THE CHILDREN ACT 1989
IN THE MATTER OF GW
Royal Courts of Justice
Strand, London, WC2A 2LL
Mrs Justice Theis
Case No: FD21P90060
and
Ms Stephanie David (instructed by Kennedys Law) for the Applicants
Ms Debra Powell Q.C (instructed by The Official Solicitor) for the 1 st Respondent
Ms Sophia Roper (instructed by Bindmans Solicitors) for the 2 nd Respondent
Hearing dates: 3 rd, 4 th and 7 th June 2021
Judgment: 9 July 2021
Approved Judgment
This judgment was delivered in private. The judge has given leave for this version of the judgment to be published. The judgment the anonymity of the children and members of their family must be strictly preserved. All persons, including representatives of the media, must ensure that this condition is strictly complied with. Failure to do so will be a contempt of court.
Introduction
The court is concerned with an application by the Cambridge University Hospitals NHS Foundation Trust (‘CUHFT’) and the Cambridge and Peterborough NHS Foundation Trust (‘CPFT’) (the Trusts) who seek orders relating to treatment for GW age 17 years, under the Inherent Jurisdiction. The other parties are GW, represented by the Official Solicitor, and PW, GW's mother.
CPFT run the unit where GW currently resides and receives treatment (the ‘Unit’). GW has been there since February 2020. CUHFT manages Addenbrooke's Hospital, who have overseen GW's treatment.
The Trusts have brought this application as they are concerned about what they say is the significant and continuing risk that GW will refuse treatment for her severe multiple sclerosis (‘MS’) and her significant wounds as a result of her self-harming.
The context of this application is that GW suffers from a chronic depressive illness, as well as a severe neurological condition, MS. Understandably, as Ms Powell QC on behalf of the Official Solicitor observes, GW has struggled with these very difficult challenges.
The Trusts seek declarations from the court that the MS and Wound Management Treatment Plans, including physical restraint, are in GW's best interests for a period of six months, until her 18 th Birthday, with a review hearing in 3 months' time. The Trusts submit having clear and consistent plans will assist GW by setting boundaries, addressing her impulse to refuse treatment in an unpredictable way and provide clarity and consistency to avoid the risk, as far as possible, of matters escalating and physical restraint being a last resort. This will avoid the serious consequences for GW's health if she does not receive the treatment, those consequences being either her death or severe permanent harm.
The application in so far as it includes physical restraint for MS is opposed by PW and the Official Solicitor, on behalf of GW. They submit it is not justified or proportionate on the evidence when undertaking the necessary balancing exercise, as having such authority is likely to be contrary to GW's best interests. In relation to the wound management treatment plan, the Official Solicitor supports that in principle; PW supports it in part but not in full, and, seeks further clarity regarding the situations it would operate in.
Prior to the hearing the Trusts refined their position to seek to use restraint in relation to the MS treatment once all other avenues have been exhausted. In relation to wound management the evidence developed during the hearing and the Trusts have now confined their position in relation to wound management in limited and circumscribed urgent situations. GW's treatment for her MS is Natalizumab (‘Tysabri’), which is administered by way of infusions at hospital every 4 – 6 weeks.
Both GW and PW attended the hearing and through skilled cross examination on their behalf by Ms Powell QC and Ms Roper they respectively explored the rationale underpinning the Trusts' position, this helped provide better clarity of what was actually being sought.
A separate question arose during the hearing as to whether authorisation is required for any deprivation of GW's liberty arising out of the arrangements for her care and accommodation at the Unit. There is agreement between the parties that the court's authorisation is not required, because GW is not deprived of her liberty. GW is there as an informal patient, has been so since February 2020 and more recently has signed an agreed list of expectations, when she asked to return to the Unit following a period at home. It is accepted GW has capacity to consent to the arrangements for her care and support at the Unit.
The hearing took place on 3, 4 and 7 June 2021 and the court heard oral evidence from the following witnesses:
1. Professor C (Consultant Neurologist)
2. Dr H (Consultant in Emergency Medicine)
3. Dr C (Consultant in Acute Medicine)
4. Dr M (Consultant Child and Adolescent Psychiatrist)
5. PW (GW's mother)
6. Dr G (Consultant Psychiatrist)
GW set out her views in writing, both directly to the court in an email, and also via the notes of her meetings with her solicitor in January and June. I have considered with great care what GW has set out.
The court is grateful for the detailed and well-crafted written and oral submissions from all of the advocates in this case, each of whom have expertise and experience in the difficult issues that have arisen in this case.
Relevant Background
GW has been residing at the Unit since February 2020. Prior to that she lived with her mother. Her parents separated in about 2009. GW experienced difficulties in school from about 2011, the extent was such that her mother requested an emergency transfer of housing.
Sadly, there was a deterioration in GW's mental health and she started self-harming from about 2013. Due to the severity of this behaviour and the lack of progress GW was offered inpatient treatment at the Unit in August 2017, when she was admitted for about 8 weeks. Following her discharge there was a period of relative stability.
In late 2019 GW was diagnosed with MS. Soon after that a close relative was admitted to hospital and, tragically, died shortly afterwards. Unfortunately GW suffered a further / second deterioration in her mental health with her self-harming behaviour escalating in late 2019, early 2020. The community mental health team considered GW required inpatient admission and she was admitted to the Unit in early February 2020.
GW remains at the Unit with a plan for rehabilitation, although the precise timing and details remain uncertain.
GW has a number of diagnoses. First, she has a severe depressive episode without psychotic symptoms which is associated with feelings of worthlessness and anxiety symptoms. Second, intentional self-harm by sharp objects which has been present for a number of years. It is described as being of an extraordinarily severe nature. This is illustrated by the information that in 2020 GW required at least 21 documented emergency admissions to hospital relating to self-harming behaviour, which have included surgical management and specialist treatment. In addition, the records at the Unit refer to 48 incidents between December 2020 and March 2021 which are mainly wound related. Third, other non-compliance with medication, which includes a history of repetitive reluctance to consent to medical treatment, including antibiotic treatment, iron supplements. Fourth, as set out above, GW was diagnosed with relapsing and remitting MS which Professor C, who oversees the management of her MS treatment, describes as being one of the most severe cases of MS he has seen in a young person under 18 years.
GW is described as a highly intelligent and verbally eloquent young woman, with a dark sense of humour. However her low self-esteem and self-worth impact on her ability to accept help, to explain her refusals of treatment and can account for her rapid transitions between emotional states from being relaxed to severely anxious, irritated or depressed. In his report Dr G describes how her ability to reason can be ‘overwhelmed by events’, particularly in ‘acutely challenging situations’ which include the requirement to give consent to invasive treatment. Whilst on one level GW recognises the need for support when that support is offered she finds herself unable to accept it and unable to explain her refusal.
This combination of cognitions has, at times, presented real challenges for those who support GW and the clinical teams who are treating her. At times GW's severe irritability and agitation are not in proportion to the triggering event, they can be started by relatively minimal interpersonal conflicts or when things do not proceed as she planned, or wanted. Such behaviour has meant there have been times when GW has either refused treatment or interrupted it, for example removing her cannula.
Prior to and after these proceedings being commenced in December 2020 there had been considerable engagement between the Trusts, GW and PW which PW recognised has brought about improvements in the treatment plans now being proposed. That collaborative process continued during the hearing.
PW places some reliance on the evidence relating to the history of wound management when restraint has been used and the consequences that have flowed from that.
On 31 May 2020 GW was taken to A&E due to her reduced haemoglobin levels. According to GW she was the subject of restraint by the ambulance staff, no other records record this although the ambulance...
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