Great Western Hospitals Nhs Foundation Trust v AA and Others
| Jurisdiction | England & Wales |
| Judge | MR JUSTICE HAYDEN |
| Judgment Date | 28 January 2014 |
| Neutral Citation | [2014] EWHC 132 (Fam) |
| Date | 28 January 2014 |
| Court | Family Division |
[2014] EWHC 132 (Fam)
IN THE HIGH COURT
FAMILY DIVISION
IN THE MATTER OF THE INHERENT JURISDICTION
AND IN THE MATTER OF AA
Royal Courts of Justice
Strand
London, WC2A 2LL
Mr Justice Hayden
Mr Michael Horne (instructed by Bevan Brittan Solicitors) appeared on behalf of the Applicant
Mr Alastair Pitblado (The Official solicitor) appeared on behalf of the 1 st Respondent
The judge gives leave for this judgment to be reported in this anonymised form. Pseudonyms have been used for all of the relevant names of people. The judgment is being distributed on the strict understanding that in any report no person other than the advocates or the solicitors instructing them may be identified by his or her true name or actual location and that in particular the anonymity of the child and the adult members of their family must be strictly preserved.
: I am concerned here with an application by the Great Western Hospitals NHS Foundation Trust to invoke the inherent jurisdiction of the High Court for declaratory relief in relation to serious medical treatment for AA.
AA is 25 years of age and she is pregnant with her first child. During the course of her pregnancy, she has been able to comply with the antenatal care offered to her. She asserts, and I accept, that she welcomed that pregnancy and her compliance with antenatal care seems to me to be evidence of it. The pregnancy is also welcomed by her partner, BB, and the couple plainly have the support of AA's parents, CC and DD.
AA is now at 38 weeks gestation. Sadly she has a history of affective bipolar disorder. She is prescribed a battery of antipsychotic medication for that condition, including lithium and Depakote for mood disorder and olanzapine and quetiapine and ablify for psychosis.
AA also has a history of substance and alcohol abuse, that likely represents her efforts to self-medicate, particularly in the early days of her illness. She has, historically, been admitted to an establishment in Swindon following a mental health assessment in 2011. It is clear that AA, like so many who suffer from this sad and debilitating condition, has only limited insight into it and to its consequences, and so she has from time to time intermittently discontinued her medication when the medication makes her feel well. She has further to progress in the understanding of her condition and of the importance of a strict medication regimen. That will be particularly important when she is a mother.
AA is now symptomatic, suffering from hypomania and puerperal psychosis. During the course of the application today, I heard from a number of witnesses, about whom I will say more shortly, but I note that AA's father, who has been with her throughout on this long journey of mental ill-health, has described her present condition as the worst he has seen. He has described her to me as very agitated, "violent" was a word he used, and "exhausted by lack of sleep."
On the evening of 26 January, AA presented to the Great Western Hospital in a confused and disoriented state, having, it was suspected, suffered a seizure prior to admission. At the initial assessment at around 8.30 pm, it was noted that her membranes had ruptured. Quite when they had ruptured it was difficult to tell, but it seemed likely that that was not very long before her presentation at the hospital. She was admitted to the labour suite and there she remains, although she has not as yet gone into labour. At 7 am the following morning, on 27 January 2014, she was detained under section 5(2) of the Mental Health Act 1983. She remains highly agitated and is largely uncooperative with almost every aspect of her obstetric care. Her father in his evidence confirmed that position.
Because AA is pregnant, it has not been possible to administer the full range or indeed the requisite dose of medication, including the antipsychotic medication, that her present florid condition would otherwise require. The dilemma for the treating clinicians, and the reason why this application comes before me today, is that rupture of the membranes gives rise to a significantly increased risk of both maternal and foetal infection until delivery. In such circumstances, the management plan would ordinarily and almost automatically move to induction of labour by the administration intravenously of Syntocinon. Such administration requires continuous CTG monitoring, both of the mother and of the foetus. The treating team is entirely clear that AA would be unable to co-operate with this type of management. Indeed, AA's father told me that she has already removed intravenous lines on more than one occasion.
I heard today from Dr Kevin Jones, a consultant gynecologist and obstetrician. He took over AA's care first thing this morning, although he has not hitherto had any dealings with her. Yesterday evening at about 9.30 pm, the Trust made an emergency application to the out-of-hours judge, who last night was Moor J. At that stage, Mr David Griffiths was the consultant obstetrician and gynecologist on duty, Moor J heard oral evidence from Mr Griffiths over the telephone. As AA had not yet entered into labour, the judge did not think it was appropriate to grant the declaratory relief that the Trust sought on a telephone application. The position could be held over, he considered, until this morning when the matter was to be listed before me. However, had AA gone into labour or begun to show signs of infection, Moor J then gave the Trust the declaratory authority it sought.
AA did not go into labour, but she had a bad night and has, if anything, become more distressed. Her father, who was obviously and understandably upset himself, told me that there had been an incident in the night where AA had run at the window and tried to get out. She was telling her father that she wanted to go to heaven.
There are broadly speaking two, at least theoretical options, in respect of AA's ongoing care. Firstly, the hospital could attempt to induce labour medically via the administration of intravenous Syntocinon. That would result in a natural labour. However, the research, as Mr Jones told me in evidence, confirming the observation of Dr Anita Sinha, the consultant gynecologist and obstetrician who prepared a statement in this application and who is part of the gynecological team, establishes that between one third and a quarter of patients who require medical inducement (particularly, Dr Jones said, in the case of a first child) require an emergency cesarean. That, he considered, would be particularly dangerous in this case. It could lead to infection and sepsis, the consequence of which for the foetus could be brain damage or death and with an increased risk of shock or haemorrhage to the mother. Given it requires the administration of intravenous medication, in the mother's present condition, it is plainly an unsuitable course.
Mr Jones, and in reality the whole of the clinical team, considers that it would be in AA's best interest to have what is termed an "elective cesarean" under general anaesthetic, chiefly because she has, as I have said, demonstrated non-compliance with the intravenous regimes during her admission so far. AA has to date permitted only one episode of electronic foetal monitoring during her admission, and she is simply unable to appreciate that such monitoring is part and parcel of a safe delivery for her baby. Indeed, she appears unable to comprehend any aspect of her treatment.
The clinical team has been concerned that, even if she were to comply with intravenous medication to begin with, that compliance would of itself not be sufficiently long standing to administer the medication safely. Rather, it is thought that her distress and agitation would increase were she to be subjected to the kind of prolonged treatment plan which is a very real prospect of induced labour. Also, whilst still fully conscious, she is at the moment unlikely to remain still or calm enough to comply.
The proposed treatment plan provides that AA will be delivered by a team of clinicians which would include the anaesthetist and obstetrician undertaking cesarean section, under general anaesthetic. She will receive ongoing treatment to include continuous observation by midwifery and mental health nurses...
To continue reading
Request your trial