Betsi Cadwaladr University Health Board v C

The High Court may exercise its inherent jurisdiction to authorise life-saving medical treatment for a 16- or 17-year-old with capacity who refuses it, where treatment is in the young person’s best interests. The young person’s wishes are important but are not determinative. The court must balance the grave consequences of withholding treatment against the harms of compulsion. Any restraint must be necessary, proportionate, least restrictive and compliant with relevant policy. Relief should be limited to the period justified by the evidence and kept under review.

The Health Board applied urgently concerning C, a 17-year-old with type 1 diabetes, who had repeatedly failed to administer insulin and had recently suffered severe diabetic ketoacidosis. C had capacity and was refusing both short-acting and long-acting insulin. Her parents supported the application. The court was asked to declare that treatment could lawfully be given against her wishes and that proportionate restraint, physical restraint or sedation could be used if necessary.

Because C was aged 17 and was not being treated under the Mental Health Act 1983, the application was made under the inherent jurisdiction. The central issue was whether overriding C’s refusal and authorising restraint were in her best interests.

1. Order made. The court declared that administering life-saving insulin against C’s wishes was lawful and in her best interests. The existing deprivation of liberty order was amended to authorise supervision and proportionate restraint by up to four members of staff, including physical restraint or sedation where necessary.
2. A 17-year-old is presumed to have legal capacity under section 8 of the Family Law Reform Act 1969, subject to the provisions of the Mental Capacity Act 2005. C was found to have capacity. Nevertheless, capacity did not prevent the court from exercising its inherent jurisdiction to protect her welfare.
3. Where a capacitous young person refuses medical treatment, the court may override that refusal in the young person’s best interests. The court must start from the premise that protection of welfare includes protection of life and that it should ensure, so far as possible, that children survive to adulthood.
4. The balancing exercise required consideration of the substantial risk of diabetic ketoacidosis, brain swelling and death if insulin was withheld, against the psychological and emotional harm caused by restraint. The life-saving benefit decisively outweighed the harms of compulsion in this case.
5. Any restraint had to remain necessary, proportionate, least restrictive and in accordance with the relevant restraint policy. The declarations were limited to seven days, with a further hearing directed for 17 September 2024. The relevant local authority and C’s parents were joined, and C was to be invited to participate and separately represented if necessary.