A Healthcare B NHS Trust v CC

Dialysis may constitute medical treatment for mental disorder under section 63 of the Mental Health Act 1983 where the physical condition requiring it, or the patient’s refusal of it, is a manifestation of the mental disorder. It is unnecessary to identify a single primary cause or a hierarchy of treatment purposes. The proposed treatment must be assessed as a whole, including ancillary restraint or sedation. Where treatment is immediately necessary to save life, prevent serious deterioration or alleviate serious suffering, section 62 disapplies section 58. Fluctuating capacity does not prevent treatment under section 63. The responsible clinician determines best interests, subject to the court’s supervisory jurisdiction.

The applicants, an NHS healthcare provider and an NHS trust, sought authority to provide haemodialysis to a detained patient who had serious mental and physical health conditions and repeatedly refused treatment. The patient’s capacity to decide about dialysis fluctuated. The court considered whether dialysis was treatment for mental disorder under section 63 of the Mental Health Act 1983, whether section 58 applied because sedation might be used, and whether a contingent declaration could be made under section 15 of the Mental Capacity Act 2005.

1. The court held that dialysis was treatment for a manifestation of the patient’s mental disorder within section 63 of the Mental Health Act 1983. The patient’s self-neglect had materially contributed to renal failure, and refusal of dialysis was itself a manifestation of the disorder. A primary-cause analysis was inappropriate. It was sufficient that one purpose of the treatment was to alleviate a manifestation of the disorder.
2. The treatment had to be considered as a whole. Section 63 was not defeated because sedation might be used to facilitate dialysis. The proposed treatment was urgently necessary to save life, prevent serious deterioration and alleviate serious suffering. Section 62 therefore disapplied section 58, making the section 63 route appropriate.
3. The patient’s capacity fluctuated. When he refused dialysis, he lacked capacity, whereas at other times he understood the consequences and wished to remain alive. Fluctuating capacity did not prevent treatment under section 63. The responsible clinician was to decide whether dialysis was in the patient’s best interests after consulting clinicians responsible for his physical health, subject to the court’s supervisory jurisdiction.
4. A contingent declaration under section 15(1)(c) of the Mental Capacity Act 2005 was unnecessary because section 63 supplied lawful authority for dialysis, including light physical restraint and chemical restraint if required. The court therefore did not exercise the MCA jurisdiction.