St George's University Hospitals NHS Foundation Trust v ZT & Anor

ZT is a 44-year-old woman born on 21 November 1981. She has been diagnosed with treatment-resistant paranoid schizophrenia and is currently detained under section 3 of the Mental Health Act 1983 in hospital.

In June 2024, ZT was diagnosed with atypical endometrial hyperplasia, a pre-cancerous condition. The risk of concurrent endometrial cancer is estimated at around 40%, and the risk of developing cancer if untreated is about 30% over 19 years. Initial conservative management was attempted with insertion of a Mirena coil, but the coil was removed by ZT shortly afterwards. ZT was subsequently prescribed, and continues on, oral progesterone. Conservative treatment reduces but does not eliminate cancer risk.

In those circumstances St George’s Hospitals NHS Foundation Trust (‘The Trust’) applies for a declaration that it is lawful and in ZT’s best interests to undergo a total laparoscopic hysterectomy and bilateral salpingo-oophorectomy (TLH BSO) as definitive treatment.

The Trust is represented by Mr Mant KC. ZT, by her litigation friend the Official Solicitor, is represented by Mr Chisholm. ZT has not personally attended at or participated in any part of this hearing although arrangements were made (and remained available) for her to do so if she wished. She had communicated in clear terms that it was not her wish to join the hearing.

At the start of the hearing the Official Solicitor reserved her position on the question of best interests until she had had the benefit of testing the evidence. Having reflected on the evidence called at this hearing and Mr Chisholm having asked the witnesses about those matters which had troubled the Official Solicitor, she did not oppose the making of the declaration sought. Whilst it has rightly not assumed prominence at this hearing where the focus has been on the decision to be made now, it is right to record that the Official Solicitor has some disquiet at the passage of time between the diagnosis and the application for the declaration.

The background to the application is in outline as follows. In June 2024, ZT was diagnosed by a pipelle biopsy with atypical hyperplasia. The likelihood for someone so diagnosed that they have concurrent early endometrial cancer present is around 40%. If cancer is not already present, there is a risk at about 30% that they will, if untreated, go on to develop cancer after 19 years.

As conservative treatment ZT initially had a coil inserted, but she removed it within a few days. Progesterone was prescribed, which ZT continues to take regularly and without objection. This conservative treatment can reduce the risk of cancer developing or spreading but it cannot eradicate the risk.

There was initially a plan to undertake further investigation but it was felt likely that ZT would object. The matter was discussed at the local gynaecology MDT in August 2024. After a range of options were discussed it was agreed that an assessment was required of ZT’s capacity to make decisions in respect of further investigations and treatment.

The process of assessing ZT’s capacity was protracted. Several attempts were made to assess ZT’s capacity without success. In late 2024 ZT’s mental state deteriorated, and it was agreed that the assessment should be delayed until she returned to baseline. Unfortunately, the lead gynaecologist, Ms A, also had a period of absence from work.

On 28 April 2025, Ms A (consultant gynaecologist) and Dr B (consultant psychiatrist) were able to complete an assessment and reached the conclusion that ZT lacked capacity to make decisions about further investigations and treatment of her atypical hyperplasia.

At a clinical meeting on 16 July 2025 following discussion of treatment options the treatment favoured was Total laparoscopic hysterectomy and bilateral salpingo-oophorecomy (TLHBSO). At a best interests meeting held with ZT’s family on 5 August 2025 that treatment was discussed. Ms A’s conclusion following the meeting was that it was in ZT’s best interests to undergo a TLH BSO.

Soon after the best interests meeting, in August 2025, ZT said that if the proposed surgery went ahead she would kill herself. As a result a further psychiatric MDT was convened, which referred the issue back to the local gynaecology MDT, and thence to a regional gynaecology MDT. The regional gynaecology MDT supported the proposal to proceed with TLH BSO.

The application for the declaration now sought was issued on 1 October 2025. At a hearing on 6 October 2025 the court gave directions for the applicant Trust to answer questions from the Official Solicitor and for the joint instruction of an independent expert psychiatrist. As it turned out the parties were unable to identify a suitably qualified psychiatrist who could report within the required timeframe. It was therefore agreed that Dr B would address the questions that had been intended for the instructed expert.

The test for capacity is set out in sections 2 and 3 of the MCA 2005. A person lacks capacity in relation to a matter if they are unable to make a decision for themselves because of an impairment of, or a disturbance in, the functioning of their mind or brain. A person is treated as unable to make a decision for themselves if they are unable to (a) understand the relevant information; (b) retain that information; (c) use or weigh that information as part of the process of making the decision; and (d) communicate their decision.

Capacity has not been in issue at this hearing. ZT lacks capacity to conduct these proceedings or to consent to the TLH BSO. She cannot, by reason of her disordered thinking which remains notwithstanding some improvements to her overall mental health (as to which I accept the evidence of Dr B), use or weigh relevant information in order to make the relevant decisions. Her thinking is markedly disordered as to matters relating to pregnancy and child birth. She is unable to relate the information about the risk of the presence of cancer or the risk of development of cancer to her own situation and does not accept that she has atypical endometrial hyperplasia.

Unsurprisingly the relevant law in respect of best interests was uncontroversial at this hearing. Sections 1 and 4 MCA 2005 provide as follows:

Thus in determining best interests, the court must consider all relevant circumstances, including (a) ZT’s past and present wishes and feelings, beliefs and values, and other factors she would be likely to consider if able to do so, and (b) the views of persons engaged in caring for her and other persons interested in her welfare (including family members).

In Aintree University Hospitals NHS Foundation Trust v James [2013] UKSC 67 at [39], Baroness Hale said:

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.'

There is a strong presumption in favour of treatment that will sustain life, but the presumption is rebuttable (Aintree at [35]).

I have heard oral evidence at this hearing from Ms A, the lead consultant gynaecologist and from Dr B consultant psychiatrist. Both witnesses impressed not only because of their own professional skills but also because of the way in which they clearly had a detailed and empathetic knowledge of ZT as a person as well as a patient.

Ms A is a consultant gynaecologist. She is the author of two witness statements in support of the declaration sought. The first is dated 29^th September 2025 and the second 3^rd November 2025. In those statements she had set out the history of her involvement, her professional opinion as to diagnosis and treatment. I have read carefully and accept the professional opinions contained within those statements which I do not rehearse in full here. She has also participated in a number of MDT meetings the notes of which have been provided to the court in a separate bundle. In her oral evidence Ms A confirmed that which she had put in writing and amplified by way of explanation how it was that she had formed the views from which she did not depart in her oral evidence.

There is, she confirmed, no doubt as to the primary diagnosis of atypical hyperplasia. That had been one of the aspects which had troubled the Official Solicitor, including because as long ago as 2014 she had noted in the medical records other gynaecological recordings in respect of endometrial thickening which might have indicated some other component to the diagnosis. Taken to it, Ms A was clear that she was confident in the diagnosis of atypical endometrial hyperplasia made in June 2024.

As to the available treatment options they are: (a) TLH BSO; (b) TLH and bilateral salpingectomy without bilateral oophorectomy i.e. surgical procedure but retaining the ovaries; (c) continued conservative treatment with oral progesterone and six-monthly hysteroscopies/biopsies; (d) continued conservative treatment without six-monthly hysteroscopies/biopsies; and (e) taking no action i.e., do nothing.

She was clear in her evidence that TLH BSO is the only definitive treatment. Amongst the matters that had been discussed with ZT, who expresses a very strong wish – and the wish if not the prospect is real – to have children, was the possibility of surrogacy and freezing her eggs. She had been explicitly clear that she did not wish to do that. This expression of wish is congruent with the evidence I heard from Dr B of ZT’s strength of wish not only to have a child but to carry and bear a child through pregnancy. If ZT’s ovaries are retained, Ms A was clear that she may require further surgery to remove them if the post-operative histology results show cancer in the uterus or fallopian tubes, which would indicate a high risk of concurrent or developing malignancy.

For women diagnosed with atypical hyperplasia conservative treatment is never recommended as a long-term option. Although it can reduce the risk of cancer developing or spreading, it cannot eradicate the risk, and regular hysteroscopies/biopsies are required to monitor that risk. Absent the hysteroscopies/biopsies it cannot be known whether cancer has developed or spread. In the relatively short term and in accordance with the Royal College of Obstetricians and Gynaecologists’ guidance, conservative treatment would be offered as an option for women who want to conceive. She would not regard it as suitable for ZT or intend to offer it as the practical likelihood of ZT conceiving (as distinct from her real wish to do so) and having a successful pregnancy is extremely low, given: (a) her age (44 years old); (b) concurrent polycystic ovary syndrome; (c) reported history when married of unprotected sex without conceiving; and (d) social circumstances (detained under the MHA and no current partner). In relation to ZT, Ms A would not be prepared to carry out any hysteroscopy as part of the six-monthly monitoring which would be required under option (c) without a general anaesthetic and so that option has to be seen as carrying with it, she said, restraint and general anaesthesia every six months.

Dr B is a consultant psychiatrist and the author of two statements in support of the declaration sought dated 22^nd September 2025 and 19^th November 2025, in which she sets out the history of her involvement and her professional opinion as to best interests. She did not depart from that which she had committed to writing but she did expand and give context to that which she had written. Very shortly before the 19^th November 2025 when she signed her second statement this witness had thought that she had detected a shift in ZT’s thinking in that she was expressing herself as open to discussion about the treatment which had seemed to be a departure in the sense of improvement from her previous thinking. It rapidly became clear when efforts were made to progress to discussion, however, that it was not in fact change. As she described this, I sensed from Dr B a real disappointment and sadness. She had known ZT for about a year and had made, very obviously, real and concerted efforts to establish a therapeutic relationship with her. I was struck by the fact that she was a witness with particular empathy and care for her patient. A small vignette came when she was being asked by counsel about ZT’s delusional thinking about pregnancy. She had described a conversation with ZT in which there had been talk of there being perhaps a miracle from God and a pregnancy notwithstanding her having no sexual partner and being detained on the ward. Asked if she had been of the view that that conversation was illustrative of the fact that her patient was obviously delusional at that time, she carefully replied to counsel that in relation to the pregnancy aspect of course it was, but that she would never suggest to her patients that it was delusional to think about miracles and God. I unhesitatingly accept her evidence.

One of the aspects which she expanded upon in oral evidence is the fact that into the balance in weighing best interests in this case is the fact that ZT has said, in response to the prospect of surgery that would remove even the possibility of her having a child, that she would kill herself. There is here a real risk of suicide. Dr B explained that she had discussed this with colleagues. In the circumstances of the ward on which ZT is detained, the risk of suicide would be managed as it has to be for a number of other patients. It was not that in supporting the application for a declaration she ignored this but rather that it was something that would require continued care and monitoring. ZT has been detained for over three years. There is no reason to think, said Dr B that she will be a candidate for release in the near future; that is something for the medium to long term

ZT’s wishes and feelings are of very significant importance. The decisions to be made here are not simply medical and clinical, but social and psychological. Mr Chisholm rightly reminds the court that it must stand in the shoes of the person who is unable to make the decision. Standing in those shoes I take account now of what I know or can infer of how she feels, and what I know and can infer of what she wishes or would wish.

Overarchingly she had expressed the view to Dr B that she does not want to die. She is, as the Official Solicitor has observed in submissions, engaged with a future. Her wish not to die weighs heavily it is said with the Official Solicitor. So too with me.

In September of this year Dr B spoke to ZT about her wishes and feelings and the following is recorded: Dr B explained that with the uterine hyperplasia, she is not sure if women who suffer from this are able to have children. Dr B explained to [ZT] that this condition can become cancer, which can cause death. [ZT] said that she doesn’t want to catch any illnesses or die. Dr B said that the gynaecologist consultant would want to remove her uterus, [ZT] refused as she wants to have children. [ZT] said that she would always refuse to have uterus removed, even if she had children. [ZT] said that according to her Muslim faith, she would not want to hurt any unborn children, therefore she would not want her uterus removed. [ZT] denied saying that she would kill herself if she had the surgery but said that she would be disappointed and go back into depression. [ZT] found this conversation upsetting and asked to leave the review.

That conversation makes plain the well-established view expressed by ZT in innumerable contexts that she wishes to have and continue to be able to have children. I hold that in my mind as I assess best interests. It is notable also however as there appears to be a step back from the question of suicide. I regard that however as something that may not represent a real shift in thinking (rather like the experience of Dr B in the period 12 – 19 November this year referred to earlier) and I have thought it preferable to continue to regard the risk attendant upon imposed surgery of this sort to include suicidal intent as well as the reference made later in the same September conversation to the fact that ZT said she would be “disappointed” and that she would go back “into depression”.

Elsewhere in relation to wishes and feelings I have the note of the Official Solicitor’s agent who attended upon ZT in hospital on 3 October 2025, from which emerges the following information: ZT struggled to speak coherently about medical issues notwithstanding the use of simple language, and was tangential in her responses. She did however speak about pregnancy and the wish to have babies, saying, “I should be pregnant fifteen more times.” She did not accept (congruent with that which is relevant to capacity) that, if left untreated, the hyperplasia would have an impact on her health. In respect of the proposed TLH BSO, she put her view squarely: “I will never do that, that’s a lack of understanding. For a lack of understanding. They put people in jeopardy of not having children. I would never do that.” It is recorded that ZT said to the Official Solicitor’s agent that having children was more important than her health, though from the clear submissions on this aspect by the Official Solicitor I do not interpret that as being a wish or close to a wish or even accepting an inevitability of death.

In considering not only her wishes but her feelings, I proceed on the basis that it is likely that she will respond negatively to being told that there is to be surgery to remove the organs which would permit her to remain fertile or with the prospect of fertility.

ZT’s family have not participated in this hearing. Their views accordingly I take as relayed by the applicant and second respondent.

The family members who have regular contact with ZT are her mother (FB), her sister (FH) and two brothers (ZH and BH). The mother and two brothers live in the same household.

The Trust’s application was served on FH and ZH (who was asked to provide it to FB and BH). The Trust arranged for the proposed care plan to be translated for FB who speaks and reads Bengali. They also offered an appointment for the family to go through other court documents with a “language line” translator. This offer was not accepted. The family were all invited to attend an RTM on 21 November 2025 but none of them chose to do so.

Based on discussions at the best interests meeting on 5 August 2025 and subsequent discussions on the ward, the picture emerges that: FH supports definitive treatment. She considers that six-monthly biopsies would be too traumatic for ZT. ZH has said that he supports the proposed treatment if it is the last and only option. In recent discussion with Dr B he said that he wanted the surgery to go ahead, although he had not discussed gynaecological matters with ZT, and ZT was more likely to discuss such matters with her mother. FB has expressed concerns about the proposed treatment. She has also said that she wants ZT to have the correct treatment. She has not indicated any wish or intention to engage in proceedings and/or actively oppose the application.

The overarching benefit of the proposed TLH BSO is that it will be curative, unless that is ZT has already cancer which has metastasised. It has emerged at this hearing that in the event the declaration is made biopsy will also be taken for investigation at surgery.

Against that significant, and as I see it life-preserving, benefit fall to be balanced the following burdens. It removes entirely even the theoretical possibility that ZT will bear children; she will be put into menopause and will perhaps require HRT. There are the common risks associated with anaesthesia heightened by ZT’s medications. There are the common risks associated with surgery: bleeding, infection and clots. Most significant as I see it in relation to the burdens are the potential psychiatric consequences, which are difficult to quantify, of surgery carried out against ZT’s will with the known risk of depression or suicide.

As I balance those burdens and benefits in the light of all I have heard and read I am satisfied that the balance tips in favour of the surgery proposed despite the significant burdens. There is no other curative treatment.

I agree that there is limited benefit in retaining her ovaries where she has rejected the notion of surrogacy and where that exposes her to the risk of further future surgery. I agree also that there is likely to be little distinction if any between the psychological impact of the lesser surgery and TLHBSO. In arriving at this best interests decision I do not overlook the gravity of this situation in which, despite the fact that I am entirely satisfied that it is the only decision which properly can be made after a consideration of the evidence and by balancing best interests, imposes on a woman who albeit without capacity has said clearly she does not want it.

For all of the foregoing reasons I will make the declaration sought and will invite counsel to draw up an order reflecting that decision.