The case of Re CA (Natural Delivery or Caesarean Section) involved a pregnant woman with a learning disability and autism who was refusing all obstetric interventions and insisting on a home delivery. The Trust applied to the Court of Protection for a declaration that it was in her best interests to undergo a caesarean section, if necessary using force.
What the Judge found "extremely concerning", however, was the timing of that Court application, which was made less than a fortnight before the baby's due date.
Reflecting this concern, the Judge highlighted the importance of following the detailed guidance given by the Court of Protection in the FG case: "Hereafter, all NHS Trusts must ensure that their clinicians, administrators and lawyers are fully aware of, and comply with, the important guidance given [in FG case] in respect of applications of this sort".
This is a good opportunity for Trusts to remind themselves of what the FG guidance requires. To help with this, we have included in this alert a brief summary of what needs to be done and when.
CA case
What was the case about?
CA was a 24 year old woman with a learning disability and autism. She was referred by her GP to the obstetric team at the local NHS Trust at what was initially thought to be around 30 weeks gestation, but subsequent scans showed to be less. She refused to undergo any gynaecological examinations or blood tests, although she agreed to ultrasound scans. CA strongly disliked hospitals/doctors and wanted to have her baby at home. However, she showed little, if any, understanding of the realities of childbirth and did not think it would involve any pain.
As a child in Nigeria, CA had been subjected to abdominal cutting, most likely under some form of physical restraint. Her mother reported that she had also undergone FGM, although CA had refused to be examined to confirm this. It was thought likely that her aversion to medical treatment was linked to her traumatic experiences as a child.
CA's treating obstetrician was of the view that an elective caesarean section would be the safest, least traumatic and most appropriate way to deliver the baby.
About two weeks before CA's due date, the Trust applied to the Court of Protection for an order that it would be lawful and in CA's best interests to deliver the baby by caesarean section.
What did the court decide?
The Court decided that CA lacked capacity to make decisions about the birth of her baby.
In assessing her best interests, the Court emphasised that CA's wishes and feelings were of considerable importance in the balancing exercise, bearing in mind that she had consistently expressed a wish to have her baby at home. However, looking at the evidence overall, the Court concluded that "…it is manifestly clear that the balance comes down decisively in favour of a planned caesarean section".
In the event, an elective caesarean section was successfully carried out the day after the court hearing.
Impact
The case was not of itself unusual. Applications to the Court of Protection in relation to pregnant women who lack capacity to make decisions about their obstetric care are relatively common and the Court looked at best interests in the usual way – i.e. a 'balance sheet' approach, weighing up the advantages and disadvantages of the various options for delivery.
However, the case is notable for the Judge's response to the Trust for not bringing the matter to Court sooner, leaving little time for the Official Solicitor - acting on behalf of CA - to consider the case and establish her views. The Judge did not mince his words here: "This extremely unsatisfactory situation has been brought about by the failure of the Trust to start proceedings at an early stage. In this respect, the Trust has manifestly failed to comply with the guidance [given in the FG case]….This guidance is compulsory reading for all professionals involved with such cases".
To avoid similar issues, it is worth Trusts reminding themselves (and their obstetric teams in particular) of the need to follow the steps summarised below.
A reminder: Steps to follow in obstetric Court of Protection cases
A full copy of the guidance can be found in the Annex to the FG case. To summarise:
An application should be made to the Court of Protection where a pregnant woman lacks, or may lack, capacity to make decisions about her obstetric care due to a diagnosed psychiatric illness (or other mental disorder) and one or more of the following applies:
- Serious medical treatment - The proposed interventions probably amount to 'serious medical treatment', including delivery by caesarean section where the merits of this are finely balanced, or where more than transient restraint is likely to be needed; or
- Use of restraint - There is a real risk that the patient will be subject to more than transient restraint; or
- Best interests dispute - There is a serious dispute as to what obstetric care is in the patient's best interests; or
- Deprivation of Liberty - There is a real risk that the patient will be subject to a deprivation of liberty which would be unlawful without a court order authorising it.
