Powys Teaching Health Board & Anor v NT & Anor

The court is concerned with an application to operate on NT to explore and remove what is thought to be a potentially life-threatening tumour from his bladder through a procedure known as transurethral resection of a bladder tumour (‘TURBT’).

The application is made by Powys Teaching Health Board (which has funding responsibility for NT) and Aneurin Bevan University Health Board (where NT resides) (‘the Health Boards’). NT is represented in these proceedings though his litigation friend BO and NT’s mother, DT, is also party to these proceedings. The court is very grateful to Oliver Lewis who represents DT on a pro bono basis.

In advance of this application the Health Boards contacted the Official Solicitor’s office in accordance with the Serious Medical Treatment Guidance [2020] EWCOP 2 and in liaison with them the Health Boards secured a local advocate, BO, who was able to act as NT’s litigation friend.

There is no issue between the parties that NT lacks capacity to make the decision regarding this proposed treatment and to conduct these proceedings.

The issue of delay in bringing this application has been a matter that has concerned the court. The Health Boards have recognised there has been some delay and apologised to the parties and the court for that delay.

The position statement filed on behalf of DT details the chronology. The need for the TURBT procedure was established in March 2025. Over the next three months NT declined the treatment four times.

The capacity assessment in late March 2025 by Dr J stated ‘Today [NT] is capacitated and agreed to have surgical intervention. He needs reassurance from staff he connects with at [Z home]. He might appear lacking capacity sometimes because of extreme anxiety and failure to communicate with staff that he does not know, and then resorts to denial and distortion of reality’. That assessment was superficial, contained no analysis of the history of NT refusing the treatment in the past and did not obviously address the reasonable foreseeable consequences (as required by s3(4) Mental Capacity Act 2005) other than recording ‘the procedure and its purpose was explained to him’. It did not accord with the court’s expectation that a capacity assessment should be “evidence-based, person-centred, criteria-focussed and non-judgmental” per CT v London Borough of Lambeth & Anor [2025] EWCOP 6 (T3), para. 60(4).

Even though NT continued to decline the procedure the issue of capacity was not looked at again. Dr K became involved in July 2025 and undertook an assessment of capacity on 13 August 2025 which concluded NT lacked capacity. The best interests meeting that decided this application should be made was on 19 August 2025, although the application was not filed until 31 October 2025. It was issued by the court on the same day.

The Health Boards state that NT’s medication was adjusted soon after the best interests meeting and there was understandable concern about the impact on NT’s therapeutic relationship with those who cared for him if the procedure was undertaken against his wishes. However, some of the delay was said to be due to what were termed ‘structural issues’ caused by the need for liaison between the different Health Boards and providers. These structural issues should be addressed without delay to ensure that is not a cause of delay in the future.

The ‘Guidelines for Managing Patients on the Suspected Cancer Pathway’ published by the Welsh Government emphasise the need for clinicians to ensure that ‘their actions promote the principle of patients waiting the shortest possible clinically appropriate time for treatment.’ (paragraph 27)NT had a condition that required the proposed treatment and the impact of delay risked the condition becoming more serious. Steps should be taken to ensure that such delays are avoided in other cases with a clear timetable agreed at the best interests meeting in the event of decision for proposed treatment as to when (if it is required) an application in the Court of Protection is made.

There is now a large measure of agreement between the parties that the court should make the order for the proposed treatment. In recent discussions with NT he requested a further scan was done through a private hospital, indicating that if that scan still showed the presence of the tumour he would agree to undergo the TURBT. That further scan was arranged, funded by a member of NT’s wider family. The results became known on 21 November 2025 and confirmed the existence of the tumour. In discussions with his mother over the weekend before this hearing NT told her that in the light of that scan result he would agree to undergo the procedure.

Even though there was that measure of agreement it was still necessary to hear oral evidence from Ms T, Consultant Urologist, and NT’s mother, DT.

I announced my decision at the end of the hearing that the proposed treatment was in NT’s best interests. The reasons for that decision are set out below.

NT, 41 years, has been known to the mental health services for many years and is currently detained under section 3 Mental Health Act 1983 at a level 2 mental health inpatient rehabilitation service, Z home. NT suffers with Treatment Resistant Paranoid Schizophrenia and Attention Deficit Hyperactivity Disorder. He has been an inpatient at Z home for his treatment since September 2023.

NT has had a limited response to most antipsychotic medications, with residual delusional beliefs and auditory hallucinations of God communicating directly with him and issuing commands.

In early March 2025 NT complained to staff of bleeding when passing urine and pain in his kidney area. Urine samples were taken which contained blood. NT was referred to hospital that day where he had a bladder scan and bloods but he refused further investigations. NT refused to answer questions from the urologist at the hospital and when the urologist explained that cancer could cause the symptoms NT responded that he didn’t have cancer and told staff he was leaving and self-discharged. When back at Z home NT refused to take the medication prescribed stating that he didn’t trust the doctor.

A few days later NT completed further urine samples which contained blood. When NT was reviewed at the hospital on 14 March 2025 he had a CT urography which revealed a 2.2cm polypoid lesion arising from the left posterior wall of the bladder. NT was advised that he had possible tumours and would need to be admitted for emergency TURBT surgery the following day.

A TURBT is an endoscopic scraping of the tumour from the wall of the bladder via the urethra. A catheter is normally used to allow any bleeding to settle and a mitomycin chemical ‘chemotherapy’ is applied. The procedure is performed under a general anaesthetic. The evidence confirmed there are no contra indications with NT’s current medication and it is recognised that flexibility will be required as to the timings, doses and method of inducing anaesthesia dependent on NT’s behaviour. The risks of the procedure include infection, bleeding, damage to the bladder including perforation which usually requires a catheter for two weeks. In rare circumstances a laparotomy may be required to repair the perforation.

Following the procedure, if the cancer is non muscle invasive, depending on the risk stratification of the bladder tumour, the MDT would follow up with local anaesthetic flexible cystoscopies for between 1 – 10 years and may offer intravesical treatments as well. Ms T gave more information about this in her oral evidence. If the tumour is muscle invasive then a cystectomy or radiotherapy will be considered, as well as neoadjuvant chemotherapy.

NT initially agreed to go through with the procedure but later withdrew his consent, despite encouragement to undertake it. He was discharged back to Z home with a plan to be offered an elective TURBT. NT was placed on four hourly nursing observations and unescorted section 17 community and grounds leave was revoked due to the need for monitoring. A file note at Z home at that time recorded NT’s resistance to undergoing TURBT surgery, he questioned whether there was anything wrong with him and stated that God had told him not to proceed. When it was suggested to him returning to the hospital for further investigations and a review of the result NT dismissed the idea stating ‘Nah, I’m fine. I’m physically well; it’s just the Clozapine’. In further discussion NT recognised he was scared but said the scan didn’t show anything.

On 24 March 2025 Dr J, consultant psychiatrist, reviewed NT following NT experiencing dizziness, low blood pressure and tachycardia. NT then agreed to have the TURBT. The following day NT was transferred to Y hospital via ambulance but then did not agree to the procedure the following day and self-discharged.

Dr J assessed NT’s capacity on 26 March 2025 to consent to TURBT. During the assessment, DT consented to the treatment and Dr J concluded that NT made a capacitous decision to agree to the proposed TURBT.

On 12 April 2025 NT’s blood pressure was within the normal range, that being the only time during the week that NT had allowed any form of physical health observation to take place.

On 16 April 2025 Dr J had a medical review with NT. NT was refusing physical intervention as he believed God had told him that he did not have any physical health issues. On 27 April 2025 NT told a nurse that God had told him his cancer had gone. Encouragement continued to be given to NT to attend the next appointments.

NT was offered a pre-operative assessment on 7 May 2025 which he initially accepted. At that appointment he was informed about the assessment and what would be involved. On 20 May 2025 he declined to attend hospital to undertake the planned TURBT. He refused to attend another appointment on 4 June 2025 and at the end of June 2025. He reported that ‘God has cured me, so I don’t need to go’.

On 1 July 2025 his GP noted no active bleeding but that NT needed iron. On 8 August 2025 NT was encouraged by his psychiatric nurse to review the CT urography scan to improve his insight into the current physical health concerns.

On 13 August 2025 a joint capacity assessment was undertaken by Dr K, psychiatrist, and Ms T, consultant urologist. This assessment concluded that whilst NT is able to understand the relevant information he is unable to weigh up the risks of not having the procedure. NT said that he did not believe he had a bladder tumour and that he did not need the procedure. Ms T brought images for NT to look at and leaflets about the procedure but NT refused to consider them. NT believed the previous CT images have been tampered with and he did not have a tumour.

On 19 August 2025 a best interests meeting was held which was attended by the Health Board’s multi-disciplinary team (MDT), NT’s community care co-ordinators, the case manager, IMCA and NT’s parents. Whilst Dr J considered NT had capacity to make the decision to refuse treatment that view was not shared by NT’s care co-ordinator, his IMCA, the MDT and Dr K who considered NT lacked capacity to make the decision and given the likelihood of the tumour being life-threatening if left untreated it was in NT’s best interests to have the procedure. NT’s case manager agreed NT lacked capacity but did not consider the procedure should be forced on NT if he opposed it due to the impact that could have on NT and his relationship with his treating team. NT’s mother then considered he had capacity to make the decision and that he should not be forced to have the procedure.

In August 2025 NT’s medication of Clozapine was increased and a secondary anti-psychotic, Amisulpride, was introduced. Dr K advised that it may take a month or two to see any changes however she considered any improvement was unlikely due to NT’s long-standing mental health presentation.

On 28 August 2025 a meeting with the relevant specialist team that deals with Therapeutic Management of Violence and Aggression took place to formulate a transition plan to take NT to the hospital for the operation and a restraint plan if that is required. Following that on 4 September 2025 a professionals meeting discussed the proposed plan to try and minimise the impact on NT. It was agreed NT would be transitioned to the general hospital in order to have the TURBT on section 17 leave and would be escorted by mental health staff from the rehabilitation centre for the duration of his inpatient stay.

On 25 September 2025 NT met his case manager but would not tolerate a discussion about the procedure and left the room. On 2 October 2025 NT maintained his position that he did not wish to have the TURBT procedure and expressed beliefs that there was nothing there and the urologists are lying.

This application was made on 31 October 2025. I made directions and a transparency order on 3 November 2025, listed the matter for a directions hearing on 5 November 2025 when I made directions leading to this hearing.

On 14 November 2025 NT met with BO and his case manager when he expressed a desire to have a private scan. This was arranged for the morning of 20 November 2025. The scan results have demonstrated that the tumour is likely not muscle invasive and, as a result, did not change the treatment options being considered.

Dr K has been involved in NT’s care since 7 July 2025. She summarises NT’s history as follows ‘I understand from the clinical records that [NT] has had several informal and compulsory admissions over the years. He has required periods of treatment in medium secure forensic services, intensive psychiatric units, low secure forensic services, as well as periods of management in seclusion due to high risks of harming others and high levels of agitation and aggression when experiencing a relapse of his mental illness. He has been well known to mental health services since the age of 11 years…’. Dr K confirmed NT has had limited response to most anti-psychotic medications. He has responded best to Clozapine therapy but chose to discontinue this prior to his most recent admissions which lead to a deterioration of his mental illness with evidence of thought disorder, paranoid and persecutory delusions, loosening of association and auditory hallucinations. NT was recalled to hospital in early 2022 due to requiring inpatient treatments and it being considered that he was posing risks to his health and the safety of others.

NT was admitted to Z home in September 2023 where he has continued to present with both negative and positive symptoms of his psychosis. NT would not engage with the rehabilitation process but was gradually introduced to social exposure and started utilising unescorted community leave between October 2023 to March 2025 with no concerns.

In her statement Dr K detailed the history outlined above and then describes the joint capacity assessment on 13 August 2025. Dr K considers NT was able to understand the information provided to him regarding the presence of the bladder tumour which necessitates further investigation. He was also able to understand the information provided to him regarding the need for TURBT, what the procedure includes and retain the information long enough to make a decision and communicate that decision. However Dr K stated NT was unable to weigh up the risks of not having the TURBT and biopsy as he believed the previous CT images had been tampered with and he does not have any tumour in his bladder. He was answering with one or two words and was quite agitated and asked them to leave him alone.

Dr K considered it would be difficult to predict how NT would react if he was to be transferred and undergo the operation against his will. She notes there is a history of verbal and physical aggression towards others when NT had experienced a relapse of his mental disorder in the past, but currently this is stable. In her statement she outlines the information from Mr M, Consultant Anaesthetist, regarding the medication options to manage NT’s situation.

Ms T, Consultant Urologist, sets out in her statement the history of NT’s involvement with the urology team from March 2025 and her involvement with NT since June 2025. In her opinion the scan result showing a 2cm tumour in the bladder is very likely to be cancerous, the only way to tell if it is muscle invasive is to do the TURBT procedure. Post operative testing will take three weeks. It can be a curative resection if it turns out to be ‘non muscle invasive’.

In her oral evidence she described the options. If it was non muscle invasive it would, depending on testing that would take about three weeks, be categorised as being low, intermediate or high risk. If low it would be monitored by a flexible cystoscopy procedure at three and twelve months followed by discharge if they are clear. If intermediate risk the treatment would involve a weekly chemical wash (delivering a liquid medication directly into the bladder via a catheter) for six weeks, then flexible cystoscopy at three and eighteen months, then annually for five years. If high risk there would be a more intense chemical wash process over six weeks, followed by three week courses at three, six and twelve months for up to three years. In addition there would be monitoring by flexible cystoscopy over a ten year period. If the tumour is shown to be muscle invasive the options are bladder removal followed by chemotherapy or no bladder removal but radiotherapy would be required. Ms T confirmed that from what she had seen on the scans she expects the tumour to be non-muscle invasive and probably in the low to intermediate risk category. Not proceeding with the operation would mean the likely bladder cancer would at some point spread outside the bladder, making it more difficult to treat or possibly become incurable.

Mr M, Consultant Anaesthetist, has been involved in NT’s care since early September 2025. His statement sets out the proposed pre-operative sedative which could be given the night before the procedure to reduce anxiety. He did not consider there were any additional risks caused by NT’s existing medication. He confirmed that NT’s behaviour on the day will likely require some flexibility to the timings, doses and method of inducing anaesthesia and the administration of medications.

Ms L is the Complex Case Specialist Practitioner for Mental Health. Her role involves completing assessments and supporting MDTs in determining and commissioning appropriate accommodation and care for individuals who require support due to the nature of their mental health illness. This involves the review of quality assurance and in NT’s case the role of case manager. Ms L has been involved with NT since 2022. In her two statements she outlines the history of NT’s mental health care and her direct involvement with him. She describes how NT has been able to establish a good therapeutic relationship with the staff at the rehabilitation unit. This is a positive change as this has been difficult for NT in the past. NT has been able to tolerate conversations with these individuals about his physical health for short periods of time with familiar staff although discussion on that topic have become more difficult and risk NT disengaging from previously positive relationships. She sets out the seven unsuccessful attempts there have been between March and July 2025 to encourage NT to agree to this procedure.

Ms L had a meeting with NT in October 2025 to complete a litigation capacity assessment. After initial reluctance NT spoke to Ms L. He was happy to discuss general matters with her relating to his mental health but when the conversation turned to his physical health ‘he became forthright in his view that he has ‘prayed on it’ and as a result it is ‘gone’. He agreed the growth ‘may been cancerous’ but it is not relevant anymore, he will not need a solicitor, or a court case’. Her statement outlines her concerns about the impact of acting against NT’s express wishes on the therapeutic relationships with staff at Z home which could increase the risk of a relapse in NT’s mental health. She considers that since his admission to Z home NT has maintained a period of stability which has not been possible previously.

Ms L’s statement details the arrangements that would be made in the event the procedure takes place setting out the framework and confirming that the team supporting NT would undertake the least restrictive steps.

Ms L’s second statement addresses the issue of delay. She sets out the history of the advice until August 2025 from Dr J that NT had capacity to make the decision and the hope that with encouragement from those he had a good relationship with he would undergo the procedure. She also outlines the need for liaison between the two Health Boards to devise a plan in the event the procedure takes place which included careful consideration of plans around the transition, the intervention itself and restraint, if required.

In her statement DT details NT’s background describing NT’s many practical talents and abilities. She describes NT’s strong Christian belief for over twenty five years. She states ‘We understand that religious delusional beliefs are a positive symptom of schizophrenia, but it is important to dispel the thought that he only began talking about God when he became mentally unwell, or that it is solely his mental illness that causes him to refer to God.’ She continues ‘We are, of course, very concerned about his physical health and want him to receive the treatment he needs. For someone who had had a very difficult and unsettled life, we would like nothing more than decisions to enable him to have as good a life as is possible’. She confirms she accepts the assessment that NT lacks capacity. She notes his case manager refers to NT wanting a private scan to confirm the existence of the tumour due to his suspicions of the medical team and confirms her sister is willing to fund that.

When NT saw his mother on 3 November 2025 he confirmed to her that if he has cancer he would like to receive treatment as he would not want to die. She supports NT undergoing the TURBT procedure and that it should be carried out as soon as possible to reduce the risks of it becoming more serious and to help reduce NT’s anxiety. In her oral evidence she confirmed she speaks to NT most days and sees him every 6-8 weeks. She had spoken to NT each day since the most recent scan result. She said NT expressed disappointment that God had not eliminated the tumour from his bladder but did agree he needs treatment and accepted the results from the most recent scans. She said she was quite confident that NT will have the procedure. She agreed the stability NT had enjoyed at Z place, had nothing but praise for the staff there describing them as ‘professional and compassionate’. She agreed it would be helpful to have a clear and simple explanation of any post operative treatment plan so that all those around NT could be giving him the same message which would assist NT in processing the information.

In her statement BO confirms she is employed by Mental Health Matters (Wales) as an advocate for people who lack capacity to engage in decisions relating to their welfare. BO met NT on 10 November 2025 to explain her role. NT confirmed he did not wish the TURBT procedure to take place but was unable to give any further information and left the room. BO visited NT with his solicitor on 14 November 2025. They saw NT with his mental health nurse. During that meeting NT confirmed he wished to have a private scan confirming that if the procedure was recommended from that evidence he would agree for it to be undertaken.

There is no issue in this case that NT lacks capacity to make decisions regarding his medical treatment in accordance with ss1 – 3 Mental Capacity Act 2005 (‘MCA 2005’).

Consequently, the focus has been on whether the proposed treatment is in his best interests in accordance with MCA 2005:

“1 The principles

(5)

An act done, or decision made, under this Act for or on behalf of a person who lacks capacity must be done, or made, in his best interests.

(6)

Before the act is done, or the decision is made, regard must be had to whether the purpose for which it is needed can be as effectively achieved in a way that is less restrictive of the person's rights and freedom of action.

4 Best interests

(1)

In determining for the purposes of this Act what is in a person's best interests, the person making the determination must not make it merely on the basis of—

(a)

the person's age or appearance, or

(b)

a condition of his, or an aspect of his behaviour, which might lead others to make unjustified assumptions about what might be in his best interests.

(2)

The person making the determination must consider all the relevant circumstances and, in particular, take the following steps.

(3)

He must consider–

(a)

whether it is likely that the person will at some time have capacity in relation to the matter in question, and

(b)

if it appears likely that he will, when that is likely to be.

(4)

He must, so far as reasonably practicable, permit and encourage the person to participate, or to improve his ability to participate, as fully as possible in any act done for him and any decision affecting him.

…

(6)

He must consider, so far as is reasonably ascertainable–

(a)

the person's past and present wishes and feelings (and, in particular, any relevant written statement made by him when he had capacity),

(b)

the beliefs and values that would be likely to influence his decision if he had capacity, and

(c)

the other factors that he would be likely to consider if he were able to do so.

(7)

He must take into account, if it is practicable and appropriate to consult them, the views of–

(a)

anyone named by the person as someone to be consulted on the matter in question or on matters of that kind,

(b)

anyone engaged in caring for the person or interested in his welfare

…

as to what would be in the person's best interests and, in particular, as to the matters mentioned in subsection (6).

…

(10)

“Life-sustaining treatment” means treatment which in the view of a person providing health care for the person concerned is necessary to sustain life.

(11)

"Relevant circumstances" are those—

(a)

of which the person making the determination is aware, and

(b)

which it would be reasonable to regard as relevant.”

The question of whether it is in NT’s best interests to have the proposed treatment needs to be considered within the statutory framework of the MCA 2005 and the MCA 2005 Code of Practice.

The relevant caselaw on best interests can be summarised as follows. In assessing best interests, the court is not limited to consideration of best medical interests: it encompasses medical, emotional, psychological and social issues. Baroness Hale in Aintree University Hospitals NHS Foundation Trust v James and others [2013] UKSC 67 at [39] and [45]. Decision makers must look at welfare [39] ‘…in the widest sense, not just medical but social and psychological; they must consider the nature of the medical treatment in question…they must try and put themselves in the place of the individual patient and ask what his attitude to the treatment is or would likely to be; and they must consult others who are looking after him or 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.’

All parties agree that NT lacks capacity to make the decision about having the TURBT.

There is also agreement that undergoing the TURBT is in NT’s best interests. Reliance is placed on the recent scan results which establish the tumour is not muscle invasive, consequently removal of the tumour with regular ongoing reviews provides NT with a strong chance of making a full recovery.

Reliance is placed on the strong presumption of preserving life (see Lady Hale in Aintree at [35]).

NT’s wishes and feelings have vacillated over whether to have the procedure although his more recent wishes have been not to agree to it as he did not believe there was anything in his bladder and the scans had been fabricated due to the doctors not liking him. He has long standing religious beliefs and has sometimes stated that he will be cured by God although his refusal to undergo the treatment has not been consistently related to his religion. On occasions this has also been due to his anxieties about the procedure. On 4 November 2025 in discussing matters with his case manager NT confirmed that if there was evidence of a cancerous growth he would want treatment. When asked why he explained that more than anything else he ‘does not want to die’.

It is recognised that forcing NT to undertake the procedure may have a negative impact on NT’s ability to trust his team at Z home who he has developed a strong therapeutic relationship with. They have sought to encourage NT to undergo the procedure with no success although there has been a recent change in NT’s views as expressed to his mother.

There is no evidential issue that NT lacks capacity to make the decision whether to undertake the procedure. As Dr K’s assessment is detailed and demonstrates NT is unable to use and weigh the relevant information to make that decision.

The medical evidence from Ms T is clear that the TURBT procedure is required. Her assessment of the information to date is that it is likely to be non-muscle invasive and that subsequent testing will categorise it as either low or intermediate. It is recognised that certainty will only come with testing but all the indications are that the procedure with only limited post operative treatment will be curative. If the procedure is not undertaken there is a real risk the cancer will spread with consequences regarding NT’s life expectancy.

The recent scan evidence has been important for NT. In his discussions with his mother since those results he has confirmed his willingness to undergo the TURBT procedure. Whilst it is recognised that he has agreed previously and then changed his mind his mother says she is confident he will proceed this time.

In undertaking the best interests assessment the court has the recent evidence regarding NT’s wishes and feelings as well as the views of his mother. The medical evidence regarding the need for the TURBT procedure is unchallenged although it is recognised that there is a need for clear communication for NT by those around him regarding the procedure and any post operative treatment. Such consistency in communication is likely to reduce NT’s anxiety which in turn will support him regarding his wishes and feelings about the procedure and any treatment proposed.

The court recognises the concern that had been expressed about the impact on NT’s therapeutic relationship with those who care for him at Z home if the procedure took place against NT’s wishes. That risk has now reduced with the change in NT’s views although bearing in mind the history there is a risk NT’s views may change. From the evidence the court shares DT’s confidence that would be managed by the team at Z home in a way that will minimise the risk to those important relationships being adversely impacted.

Having considered all the evidence I am satisfied that the orders sought in this case are in NT’s best interests and approve the plans that underpin them with the addition of the communication plan raised in the evidence during the hearing.