St George’s Healthcare NHS Trust v S (R v Collins, Ex parte S)

A competent adult may accept or refuse medical treatment, and detention under the Mental Health Act does not of itself remove that capacity. A court declaration cannot authorise treatment contrary to a competent and informed refusal. Where capacity is absent, treatment must be directed to the patient’s best interests, normally subject to any reliable advance directive. Hospitals should identify and assess doubts about capacity urgently, secure representation for the patient in any court application, and provide the court with full and accurate information. These are guidelines, not inflexible rules; urgent circumstances may make full procedural compliance impracticable.

In a further judgment, the Court of Appeal approved revised guidelines after receiving written submissions from the parties and professional and public bodies. The case had exposed difficulties for hospital authorities where a pregnant patient might require Caesarean surgery and there was serious doubt about her capacity to accept or refuse treatment.

The Court stated that the guidance applied more generally whenever a patient might need surgical or invasive treatment and capacity was in issue. It addressed competent refusal, best-interests treatment for an incapable patient, assessment of capacity, representation in High Court proceedings, the information required for an emergency application, and the effect of urgency.

1. The Court approved revised guidelines. The supplied further judgment does not state the formal disposition of the underlying appeal. Its operative act was to set out and approve guidance founded on basic legal principles concerning consent and capacity.

2. A competent patient may accept or refuse treatment. Detention under the Mental Health Act does not necessarily remove competence. If a competent patient makes an informed refusal, a High Court declaration is pointless. The authority should instead make and retain a clear evidential record of the advice given and of the patient’s informed decision.

3. If a patient lacks capacity, whether permanently or temporarily, care and treatment must be determined by the authority’s judgment of the patient’s best interests. A reliable advance directive made before incapacity should normally govern treatment and care. A declaration may be sought where there is reason to doubt the directive’s reliability or application to the circumstances.

4. An authority should identify capacity concerns promptly and arrange a priority assessment. Serious or complex cases may require an independent psychiatrist, ideally one approved under section 12(2) of the Mental Health Act. Where court proceedings may be required, the authority should obtain legal advice promptly, notify the patient’s solicitors, and involve the Official Solicitor where the patient cannot instruct solicitors.

5. The hearing should be inter partes. An order made in an unrepresented patient’s absence will not bind that patient and gives the authority no useful declaration. The court must receive accurate, relevant information about the proposed treatment, alternatives, risks, refusal, capacity and, where applicable, best interests. Emergency applications remain subject to prompt subsequent procedural compliance, but the guidelines are not inflexible where delay may seriously damage health or endanger life.

• Court of Appeal (Civil Division) — in this further judgment, the Court approved revised guidelines concerning capacity and consent: [1999] Fam 26; [1998] EWCA Civ 1349.

No lower-court decision or earlier appellate stage is stated in the supplied judgment text.