QQ, Re

In view of the reasonably late hour and the other work in my list, I propose simply to announce my bare findings. If any party wishes me to give fuller reasons for the decisions I have made then I am more than content to do so and would do so on Friday of this week.

This is an application brought by A psychiatric hospital in relation to QQ who is 26 years of age and has a diagnosis of an emotionally unstable personality disorder and schizophrenia. QQ also has certain belief systems which are set out fully in the papers, but for what I hope are obvious reasons I am not going to dwell upon those or go into detail about them in announcing my decision.

Dr G, QQ’s responsible and treating clinician for the last 12 months, has prepared three reports, which I have read, and she has given brief oral evidence before me today. I had the benefit of meeting Dr G at the hospital when I met with QQ this morning briefly to introduce myself and to enable QQ to tell me what she wanted to say to me about her treatment. Without hesitation I accept entirely the evidence of Dr G, that throughout the time that she has been involved with QQ she has lacked capacity to make decisions on the issue of her treatment in relation to receiving anticoagulation medication.

It follows that I do not accept that when QQ made an advance decision in August 2015 in relation to her treatment that she was capacitous and therefore that it is a valid or lawful advance decision. If I were to be wrong on that issue, I accept Mr Wenban-Smith’s submission that the contrary views that QQ has recently and fleetingly expressed from time to time, namely that she would accept treatment, would not of themselves invalidate, pursuant to s 25 ss2 (c) of the Mental Capacity Act 2005, what would otherwise have been a valid advance decision.

The issue is that, in addition to her psychiatric difficulties, QQ suffers recurrent episodes of deep vein thrombosis. They cause her pain, but they have the potential, as advised by the haematologist, to have far more serious consequences - were pulmonary embolisms to form after the deep vein thrombosis then it could ultimately lead to QQ’s death. There has been a lack of clarity and equivocation about the advice received by the treating psychiatric clinicians from the haematologists as to the best interest decision in terms of treating QQ’s DVT. In the past there has been advice that it should be treated by anticoagulant injections. That advice has sometimes been withdrawn.

Most recently as at this morning, Dr A, one of the haematologists at A general hospital who has been involved in advising Dr G on QQ’s haematological treatment, advised that there were three options for QQ: (i) that she received anticoagulant medication by injection; (ii) that she received a new oral form of medication in respect of which there is now an antidote that can very quickly reverse the anticoagulant effects of that medication should the need arise - if, for example, QQ were to bleed; or (iii) there is a surgical procedure to insert a filter into QQ to prevent any pulmonary embolism reaching the lungs. Dr A’s advice to Dr G was that options (i) and (ii) should be explored before the dramatic course of invasive procedures (option iii) were considered.

Dr A’s advice and recommendation on the need for prophylactic, as opposed to treatment-specific, anticoagulant medication very much depended upon the perceived risk that QQ would self-harm, as she has done in the past, which would lead to a risk of bleeding. If there were a modest or high risk of bleeding then Dr A would not advise the treatment. If the risk of bleeding were low then he would recommend the use of prophylactic anticoagulation treatment either by injection or by oral tablet form.

Dr G advises that although in 2012 and 2013 there had been episodes of QQ self-harming by inserting objects into her stomach, culminating in a particularly serious episode in December 2014. Since then, save for a relatively minor incident in March 2015, there has been no episodes of QQ self-harming which have led to her bleeding. That is in very large measure as a consequence of the care regime in place on the Extra Care Unit at the hospital, where two members of staff are within arm’s reach of QQ throughout each hour of the day, each day of each week. It is proposed for the present that that care regime should continue. The longer term hope and plan is that, as QQ makes progress, it may be possible to have less restrictive care provision in place. Of course were that to happen then there would need to be a re-evaluation of the risk of self-harm and the risk of bleeding and, consequently, a re-assessment of the necessity and benefit of QQ continuing on prophylactic anticoagulants. But as matters stand, Dr G advises - rightly in my judgment - that although QQ still has a current intention to self-harm, the risk of self-harm actually occuring is low and that the care regime has been successful.

Accordingly, in those circumstances Dr A would recommend that QQ be prescribed anticoagulant medication on a prophylactic basis. Although on the whole QQ has refused to consent to such medication and has objected to receiving such medication either by injection or in tablet form, very recently, on or about 26 February, she told Dr G that because her leg was painful she would agree to take tablets and to take medication. When it was discussed with QQ this morning she agreed that she would take tablets. When I saw her in my brief interview, QQ started by saying that she would take the medication by tablets, then said that she was not sure and then said that it would depend upon how she felt and her mood. She also told me that her acceptance or not of the need for her to receive anticoagulant medication varied and depended again upon her mood, by which I took it to mean the difficulties and belief systems that she has.

On the totality of the evidence as it is, accepting as I do the advice and recommendations of both Dr G and Dr A, I am in no doubt that it is in QQ’s best interests to receive anticoagulant medication. I am satisfied that because of QQ’s mental health difficulties and her belief systems she is not able, now or in the past, to weigh the information that she receives. She is not able to weigh and reach a consistent conclusion on the medical need for her to receive this medication. Nor is she able to remain consistent in her ability to cooperate with the clinicians treating her, whether in relation to taking medication orally or by way of injection. I fully understand and accept that one concern that QQ has about receiving injections is that they are painful and like a bee sting and that they hurt her for about half an hour afterwards. Whilst that is a reason for her opposing injections, it is not in my judgment the dominant or causative reason for her to oppose the injections. As I have already explained in my judgment her principal opposition results from her mental health problems and belief systems.

Accordingly, I am quite satisfied on all of the material available to me that it would be in QQ’s best interests to receive the anticoagulant medication on a prophylactic basis. In the first instance that should be by way of oral form, by way of tablets, but as I explained to QQ at the hospital today, if she were not to be consistent in taking those tablets twice daily when she commenced on that form of treatment then it would be necessary for her to be treated by way of injection because the risk of her suffering further episodes of DVT and the potentially life-limiting consequences are such that she needs this anticoagulant medication to reduce those risks.