JK v A Local Health Board

An adult with decision-making capacity may refuse food and life-saving treatment, even where the decision is unwise or likely to result in death. For a detained patient, compulsory treatment under Mental Health Act 1983, section 63, requires the proposed treatment to be for the mental disorder or one of its symptoms or manifestations within section 145(4). The court determines that question on a full merits review, informed principally by medical evidence. A capacitous decision connected with mental disorder may nevertheless fall within section 63. The inherent jurisdiction cannot be used simply to reverse the outcome of the statutory schemes where the circumstances are already addressed by the Mental Capacity Act 2005 and the Mental Health Act 1983.

The Health Board sought declarations concerning the possible compulsory force-feeding of JK, a detained adult diagnosed with autism spectrum disorder who had repeatedly refused food and made advance decisions refusing medical intervention. It relied principally on section 63 of the Mental Health Act 1983, alternatively on the inherent jurisdiction and the Mental Capacity Act 2005.

The medical evidence established that JK understood the consequences of refusing food, could weigh the relevant information and had capacity to make the relevant decisions. The central issues were whether his refusal to eat was a manifestation of his autism, whether force-feeding was capable of falling within section 63, and whether the court could determine those questions before a final treatment plan and clinical decision had been made.

1. Capacity. JK had capacity to litigate and to decide whether to refuse food and medical treatment. Capacity was decision-specific. His understanding of the consequences, ability to weigh the relevant information and communication of his decision satisfied sections 1 to 3 of the Mental Capacity Act 2005. An unwise decision did not establish incapacity.
2. Inherent jurisdiction. The inherent jurisdiction protects vulnerable adults where a statutory lacuna exists, including where their will has been overborne by external coercion or undue influence. It cannot be used merely to reverse an outcome produced by the statutory schemes. JK’s circumstances were contemplated by the statutory schemes, and his autism did not make him vulnerable in the relevant sense because he retained capacity and his decision was not overborne by an external factor.
3. Section 63. The responsible clinician, rather than the court, ordinarily decides whether compulsory treatment should be given under the Mental Health Act 1983. Nevertheless, where the legal characterisation of proposed treatment is uncertain, the court may grant declaratory relief. The court must decide the issue by a full merits review, not by ordinary judicial-review restraint.
4. The refusal to eat was a manifestation of JK’s autism. The court placed substantial weight on the evidence of the specialist psychiatrist, including the evidence that rigid, demand-avoidant and crisis responses were characteristic of autism, and that food-related difficulties formed part of JK’s presentation. It was unnecessary to have extensive longitudinal evidence before reaching that conclusion.
5. Force-feeding was therefore capable of being treatment for a manifestation of JK’s mental disorder under section 63. That conclusion did not establish that force-feeding was in his best interests, medically necessary, or treatment intended to alleviate or prevent worsening of the disorder under section 145(4). The intrusive nature of force-feeding required close consideration of article 3 of the ECHR and medical necessity.
6. The Health Board had not yet completed its treatment plan or made a clinical decision to force-feed JK. The matter was therefore not finally determined. JK was given liberty to apply to restore the issue to the Family Division if the Health Board later decided to force-feed him.

First-instance decision. No prior appellate decision is stated in the judgment.