St George’s University Hospitals NHS Foundation Trust v MN

MN is 54 years old. He currently lives in a specialist residential care home in London for people with severe mental health conditions, and is subject to a Standard Authorisation granted pursuant to the DoLS Scheme under Sch.A1 of the Mental Capacity Act 2005.

On 16 July 2025, St George’s University Hospitals NHS Foundation Trust (“the Trust”) applied to the Court of Protection for:

The Trust’s plan is to carry out these steps in the next 2 to 4 weeks. At the moment, the 7 August is the intended date for all the tests to be undertaken, after which an MDT meeting would take place on 15 August 2025 to evaluate treatment options.

MN’s only known relevant family member is his mother who has no role in MN’s medical care. She does not wish to be involved in the proceedings but would like to be notified of the outcome of any medical investigations.

The parties are the Trust and MN by his litigation friend, the Official Solicitor. The Official Solicitor is supportive of the application.

I have before me the witness statement of MN’s treating Colorectal Surgeon, as part of the bundle filed for the hearing, and heard oral evidence from him.

MN has a long standing history of chronic paranoid schizophrenia dating back some 30 years during which he has been admitted to hospital on at least 10 occasions under the Mental Health Act 1983 or voluntarily, most recently between 2018 and 2021. At times the schizophrenia has been comorbid with alcohol use. He receives anti-psychotic medication, and is able to access the community. His mental health is said to be comparatively stable.

He has had long standing persistent delusional beliefs and auditory hallucinations. These include healthcare professionals attempting to harm him and attributing symptoms to incorrect causes such as insect infestation. He has regularly displayed aggressive behaviour to clinical staff and care workers, including multiple incidents of assault, often prompted when his beliefs are challenged.

In September 2024, he was referred by his GP to the colorectal team at St George’s Hospital with an anal mass which imaging suggested was strongly suspected to be cancerous. He has attended clinics , but has repeatedly declined investigation, and displayed aggressive behaviour to the clinical and healthcare teams. The team consider that the diagnosis needs to be confirmed, to establish if it has spread, and to formulate a plan to treat and manage MN.

The Trust properly acknowledges that the delay in this case is unsatisfactory, although it is in part mitigated by MN’s non-cooperation. Given that he was suspected of having cancer in October 2024 (when he was first seen at hospital after the GP referral), and was assessed as lacking capacity in February 2025. The anal mass has grown and MN is reported to be experiencing increasing amounts of pain. I do not consider that, despite the challenges of the case, this delay can remotely be justified, and in my judgment the Trust should review why it has taken so long to embark on legal proceedings and what lessons can be learned.

MN has demonstrated some understanding that the team believe he has cancer but does not recognise the need for further investigation, and says he does not want it. The use of the word “cancer” makes him distressed and, at times, verbally aggressive. He does not appreciate the risk of non-intervention, saying there is no point in investigative examination. The evidence is that he is unable to retain and weigh the pros and cons of the proposed testing.

MN is aware that there are unwanted symptoms in the anal area, and says they hurt sometimes. He believes they are due to bed bugs. He does not understand the need for a biopsy. He has referred to removal of clitorises, and asked why the doctors would want to castrate him. He has said that the scans would examine his head and he wanted the doctors to read his brain. He has spoken of the team wanting to commit euthanasia and female genital mutilation. He treats clinicians with what one has described as a “torrent of swear words and insults”.

Although in general he has expressed to the clinicians his opposition to testing, he has on occasions indicated to his Independent Mental Capacity Advocate (“IMCA”) a willingness to undergo investigations.

The Official Solicitor’s agent met MN at his home yesterday. At times it was not possible to make out what he was saying, and some of what he said was delusional and nonsensical. He said that he had never “queried” going to hospital to have a general anaesthetic and “I don’t mind doing that”. He nodded when asked about the CT and MRI scans. He reiterated that he does not believe he has cancer. He said that he is a high risk kidnap victim. He said “I don’t want to die at all”.

The statutory test in the Mental Capacity Act 2005 (“the Act”) is as follows:

There is no dispute that MN lacks both litigation capacity and capacity to make a decision in respect of diagnostic testing. The cause is his paranoid schizophrenia, which amounts to an impairment or disturbance of the mind. He is unable to retain, use and weigh information relevant to legal proceedings, and unable to instruct a lawyer. He is unable to retain, use and weigh the risks and benefits of the proposed investigations. In particular he does not, as a result of his schizophrenia, fully understand the possibility that he may have cancer, and the advantages and disadvantages of further investigation. Having read, in particular, the evidence of MN’s treating clinician and a capacity assessment dated 9 April 2025, I am satisfied that MN lacks the relevant capacity and there is nothing to suggest that his capacity to make decisions is likely to improve.

The statutory principles are set out at s4 of the Act.

The jurisprudence has emphasised the need to construe best interests broadly, most notably in Aintree University Hospital NHS Trust v James [2013] UKSC 67.

“[22] Hence the focus is on whether it is in the patient's best interests to give the treatment rather than whether it is in his best interests to withhold or withdraw it. If the treatment is not in his best interests, the court will not be able to give its consent on his behalf and it will follow that it will be lawful to withhold or withdraw it. Indeed, it will follow that it will not be lawful to give it. It also follows that (provided of course they have acted reasonably and without negligence) the clinical team will not be in breach of any duty toward the patient if they withhold or withdraw it.”

“[39] The most that can be said, therefore, is that in considering the best interests of this particular patient at this particular time, decision-makers must look at his welfare in the widest sense, not just medical but social and psychological; they must consider the nature of the medical treatment in question, what it involves and its prospects of success; they must consider what the outcome of that treatment for the patient is likely to be; they must try and put themselves in the place of the individual patient and ask what his attitude towards the treatment is or would be likely to be; and they must consult others who are looking after him or are interested in his welfare, in particular for their view of what his attitude would be.”

“[45] The purpose of the best interests test is to consider matters from the patient's point of view. That is not to say that his wishes must prevail, any more than those of a fully capable patient must prevail. We cannot always have what we want. Nor will it always be possible to ascertain what an incapable patient's wishes are. Even if it is possible to determine what his views were in the past, they might well have changed in the light of the stresses and strains of his current predicament. In this case, the highest it could be put was, as counsel had agreed, that "It was likely that Mr James would want treatment up to the point where it became hopeless". But insofar as it is possible to ascertain the patient's wishes and feelings, his beliefs and values or the things which were important to him, it is those which should be taken into account because they are a component in making the choice which is right for him as an individual human being.”

There is a strong but not irrebuttable presumption to favour a course of action which will prolong life: Re J (A minor) (wardship: medical treatment) [1991] Fam 33 at page 46 (a case concerning a child but equally applicable to an adult patient).

In weighing up best interests, where the wishes and feelings of the patient can be ascertained, they must be given proper consideration but are not determinative. The weight to be attributed to wishes and feelings will differ depending on such matters as how frequently they are expressed, how consistent the views are, the complexity of the decision and how close to the borderline of capacity the person is.

In this case I have come to the clear conclusion, having had regard to all the evidence and submissions in the round, that the application should be granted, and the care plans approved, for the following reasons:

At the request of the parties, I will adjourn to a hearing in September at which the court can consider any supplemental application for authorisation of treatment.