FD24F00084 - [2025] EWHC 920 (Fam)

MC has suffered from type 1 (insulin dependent) diabetes for many years. For much of this time his compliance with treatment has been poor, and during his time in custody, he has deliberately mismanaged his diabetes.

As a result of his mismanagement, he now has serious complications associated with poorly controlled diabetes, severe hypertension and peripheral vascular disease. He is also non-compliant with blood tests which are necessary to monitor blood glucose control for people with diabetes (HbA1c test), and with blood glucose testing which is necessary to keep daily blood glucose levels within a safe range and avoid hypo or hyperglycaemic episodes. Optimum blood glucose control reduces the risk of development of complications. He does not refuse all treatment. He is for example willing to take insulin in the evening, if not always then at least most of the time, but not to have his blood sugar levels checked immediately prior to the administration of that insulin by a healthcare worker on the ward.

In relation to his earlier treatment, it is significant that MC required, in January 2024, a below-the-knee amputation which was secondary to gangrene and sepsis. This arose because of his poor compliance with diabetes treatment and management. He now requires the use of a wheelchair as a consequence. Dr Nabais (consultant interventional cardiologist, Salisbury NHS Foundation Trust), instructed by the Trust to provide a second opinion, describes MC as now having “end stage complications of diabetes”. MC has developed micro-vascular complications of diabetes, including diabetic retinopathy (damage to the back of the eye), diabetic neuropathy (nerve damage) and diabetic nephropathy (chronic loss of kidney function).

The treatment plan for MC's multiple serious complications, connected with his poorly controlled diabetes, should be:

MC refuses to engage with the above plan. He refuses most of his daily insulin, refuses the necessary associated testing (blood glucose and blood testing), and refuses to take the recommended prescribed medication for his (end) stage 3 hypertension.

The Trust’s position is that MC's refusal to accept medical treatment for his physical health, which for the purposes of this application embraces his type 1 diabetes and associated end stage symptoms, severe hypertension and peripheral vascular disease and infected left foot, is a manifestation of his severe personality disorder. The treatment for those identified physical health conditions, the Trust contends, is medical treatment within the scope of section 63 MHA and that from that it follows that his consent is not required for medical treatment to be given pursuant to section 63 MHA. Since MC does not wish to receive treatment, he would have to be subject to restraint and administration of treatment forced upon him which in the circumstances of this case would also carry with it the prospect of exacerbating the consequences of some of his physical health conditions – such as, for example, a marked further rise in his already high blood pressure – with adverse outcomes. The Trust therefore seeks a declaration that it is lawful for MC's treating clinicians not to use force to provide him with medical treatment for his physical health needs even if this leads to adverse health consequences including MC's early death.

On behalf of MC, it is also argued that it is not in his interests for medical treatment for his physical conditions to be forced upon him or for restraint used to deliver such treatment. It appears from the document filed on his behalf that there is an acceptance of the evidence filed on behalf of the Trust that any attempt to use restraint would put him at severe and immediate risk of harm. Since he is capacitous to conduct these proceedings and not represented through the official solicitor, it is further contended, on his instructions, that he does not have a relevant mental illness - he has long disputed the diagnosis of severe personality disorder; that he wishes to make his own decisions about treatment of long-term physical health conditions, and that the treatment proposed cannot properly be said to be treatment that will treat symptoms or manifestations of a mental disorder. So far as the intended treatment set out at paragraph 8 above, it has been argued before me, and set out in detail in writing, that all of that which is listed is directed at treatment for his type 1 diabetes and does not relate to treatment for a manifestation of his mental disorder. It follows, on MC's case, that the medical treatment contemplated does not fall within section 63. If I accept that, it then follows that the declaration sought that as to the lawfulness of not administering treatment is inapposite. If on the other hand I am against the primary position that the treatment does not fall within section 63, MC invites me to make the declaration sought by the Trust since that is consistent with the overarching outcome he seeks i.e. that treatment will not be forced upon him.

The interested parties described themselves as ‘neutral’ on the substantive issue but were keen, in the event that there were to be any declaratory relief for the Trust, to have the benefit of the same relief.

The subject matter of this application does not relate to treatment which is immediately necessary to save MC's life. If urgent treatment is immediately necessary to save MC's life, MC will be treated as would be the case for any other patient. It will be for the relevant clinicians, at the time the need arises to exercise their clinical judgment, to decide what the available treatment option(s) are , and whether restraint (including through physical, chemical or mechanical restraint), is necessary to provide life sustaining treatment to him and for such treatment to be provided under Part 4 of the MHA under the direction of MC's responsible clinician. There is no area of disagreement between the parties as to this and no issue taken with it on MC's behalf. It is notable that MC has said both that he does not want to die and that in an emergency situation he would want to receive treatment to save his life.

At this hearing I have heard evidence from Dr B, consultant forensic psychiatrist, who was instructed to give an independent assessment of MC's capacity to make informed decisions on health and treatment issues and Dr A, consultant forensic psychiatrist, who is MC's responsible clinician at Rampton. Each of them had provided written evidence which I had read in advance of the hearing. As well as the oral evidence from those two witnesses, which it will be convenient to consider elsewhere in this judgment, there was a large volume of documentary material which included a Report by Prof Handran Soran FRCP Consultant Physician and Endocrinologist employed by Manchester University NHS Foundation Trust dated November 2024, a Report by Dr Sergio Nabais MRCP Consultant Interventional Cardiologist date December 2024 both of whom were instructed by the Trust prior to the institution of proceedings to provide second opinions. Dr C who has responsibility for his physical health conditions at Rampton, had drawn together an update on MC's three main physical health conditions under consideration by the court. I had also MC's own witness statements of evidence dated December 2024 and February 2025. He had been explicit that he neither wished to attend (remotely) at the hearing nor to give oral evidence.

It is neither necessary nor would it be practicable to replicate in this judgment all of the evidence which I have heard and read at this hearing. Rather I will make reference to that which has influenced my thinking in arriving at the conclusions I have reached. I have read carefully and found illuminating and informative that which I have received in written form from all of those who have in their differing spheres provided health care to MC. I took care to return to and to read again following the oral evidence and submissions MC's own written statements.

From all that I have heard and read, it is clear that MC's health position has continued gradually to decline. In November 2024 he developed an infected diabetic left foot with cellulitis. Within the evidence is contained the view of the vascular surgeon at Sheffield Teaching Hospitals (who assessed MC at Northern General Hospital) that MC was at high risk of sepsis arising from of his uncontrolled diabetes and high blood pressure. The discharge summary from the vascular surgeon includes reports of deliberate interference by MC with the healing process of the foot, by placing the foot in faeces. I bear in mind that I have not heard evidence about that aspect which MC does not accept. His disinclination to cooperate with treatment in relation to the diabetic foot within the context of i) having lost already one leg, ii) understanding (as I accept on the evidence he does) the consequences of not complying and iii) his explicit statement that he does not want to die, underscores the complexity of the situation from a psychiatric perspective. The more so, given the unanimous opinion from those qualified to give it, that his actions are not actions of intentional self-harm.

His vascular surgeon considered that with persistent inadequate metabolic control of his diabetes, MC's life expectancy would be another 1 or 2 years. Should he develop sepsis, amputation of the remaining leg would be required, and which posed a risk of death. Follow up by the diabetic team was indicated “to ensure he was compliant with his diabetes medication for proper glucose control”. MC is not currently in a critical state but remains non-compliant with treatment assessed by his clinicians as necessary for his physical health. In those circumstances there is a consensus of medical view that the ongoing risk of life-threatening complications remains and is increasing.

Professor Soran from whom, in contemplation of this application, a second opinion was sought by the Trust, in November 2024, regarded MC's case as “very challenging”. Within his report he provided a non-exhaustive list of the risk factors which arise from MC's mismanagement of his physical health issues associated with his advanced and end stage diabetes. The most significant he identified as: “Hypoglycaemia and possible brain damage; Severe hyperglycaemia, diabetes ketoacidosis, and possible mortality; A potential risk of hypoglycaemia if MC receives his fast-acting insulin and refuses to eat; and risk of uncontrolled blood pressure and its complications including stroke and acute myocardial infarction”. Those significant aspects were to be seen within the context of other complications of uncontrolled diabetes and hypertension, including the increased risk of atherosclerotic cardiovascular disease, progression of MC's microvascular complications (retinopathy, nephropathy and neuropathy), and increased risk of infections.

Dr Nabais who as set out above had given a second opinion in December 2024 concludes in his written evidence‘As a result of his non-compliance and uncontrolled hypertension, he is at high risk of future cardiovascular events and hypertensive complications, including myocardial infarction, stroke, heart failure, kidney failure, intracerebral haemorrhage, acute heart failure with pulmonary oedema, acute kidney injury, hypertensive encephalopathy, and aortic dissection’. In contemplation of treatment against MC's wishes under the auspices of section 63 MHA, his clinical view is that this would be inappropriate and would carry with it significant risk, expressed in these terms: “the use of restraint to enforce anti-hypertensive medication could worsen his high blood pressure. This would be associated with a disadvantageous risk of acute complications, including stroke, heart attack, aortic dissection, or heart failure. From that point of view, restraint would be counter-productive".

In reaching that view, Dr Nabais was clear that he had been informed by the medical records from which it could be seen that past experience indicated that MC would be likely to resist strongly and that accordingly high levels of physical and mechanical restraint would be necessary. The process of restraint (again based on past experience) would be commensurately stressful and distressing for him. It was to be predicted that MC's anger would directed at the clinical team and would likely result in yet further disengagement from treatment and breakdown in the already fragile therapeutic relationship.