Posted by THE HIGH COURT[2021] IEHC 836High Court Ref. WOC10345
WARDS OF COURT
IN THE MATTER OF MS. M HEALTH SERVICE EXECUTIVE APPLICANT-AND-MS. M (A PERSON OF UNSOUND MIND NOT SO FOUND REPRESENTED BY HER GUARDIAN AD LITEM)
RESPONDENTJUDGMENT OF Ms. Justice Niamh Hyland delivered on 20 December 2021
Summary
1.Ms. M is aged 44. Unfortunately, Ms. M has suffered from severe treatment resistant anorexia nervosa for over 25 years. Ms. M is married, and her husband has clearly been an enormous support to her throughout the course of her long and intractable illness.
2.Because of the very serious risks posed by this illness, Ms. M was made a ward of court on 29 January 2020. Pursuant to the wardship jurisdiction, she has been treated on a coercive basis, including involuntary admission to both a psychiatric unit in Ireland and a specialist hospital for the treatment of anorexia in the UK. I heard Ms. M give evidence on three different occasions. On each occasion, I was impressed by her fierce determinationand keen intelligence, and the strength of personality she displayed.
I should add that despite Ms. M’s history to date, I am hopeful that following the making of these orders, Ms. M may agree to follow the advice of her medical team, and thus maximise her chances of avoiding premature death
3.For the reasons I explain below, I am making the orders sought by the HSE, which will have the effect that her treating team will no longer provide treatment to her on a coercive basis. Given Ms. M’s extremely fragile state of health, this may well result in her early death from anorexia. However, having carefully considered the best interests test, I consider these orders are in her best interests.
5.Ms. M has attended local mental health services and Cork University Hospital (“CUH”) over the past decade for management of her eating disorder, although her history of disordered eating in fact goes back 25 years. Between 2011 and 2019 her admissions to hospital were typically prompted by severe emaciation and acute medical concerns. During those admissions Ms. M complied only partially with recommended care (including meal plans and bed rest) until her weight and medical status were sufficiently stable to allow her to be discharged or for her to discharge herself from hospital against medical advice.Worsening of Medical Condition
6.On 2 November 2019, Ms. M was admitted to CUH as an acute medical inpatient following her presentation with collapse, hyponatremia and hypoglycaemia secondary to malnutrition. Following her admission, she complied only variably with medical recommendations for re-feeding and physical activity restriction and refused food and naso-gastric re-feeding (“NG feeding”) while requesting to leave the hospital.
7.On 19 November 2019 Ms. M’s treating consultant psychiatrist, Professor Eugene Cassidy, wrote a report seeking an endorsement by the High Court to allow for the delivery of necessary acute medical care and NG feeding to Ms. M. The report noted the extensive history of her condition and stated that her compliance with her recommended care had deteriorated despite the best efforts of the multidisciplinary team (“MDT) in the acute hospital and the daily support of her husband. The report noted that she continued to exercise against advice, she refused or delayed feeding to the extent that her cumulative weekly caloric intake was well below optimal calorie requirements and that she refused oral supplements and offers of anxiolytic medication to facilitate refeeding.
8.In those circumstances, in the opinion of her MDT, re-feeding and acute inpatient care was in her best interests. In the opinion of Prof. Cassidy, Ms. M lacked the capacity to refuse re-feeding as, because of her severe anorexia nervosa, she was unable to use and weigh the information necessary to make the decision. The MDT further indicated that once Ms. M was medically stabilised they intended for her to be transferred to an inpatient mental health care facility, possibly a specialist inpatient eating disorder treatment unit in the UK.
9.On 10 December 2019 Prof. Cassidy reported that Ms. M had stabilised somewhat with acute inpatient care and NG feeding but she remained severely underweight with a BMI of 11.8 and an ongoing medical need for re-feedingand further weight gain. He reported that her compliance with feeding and exercise recommendations remained sub-optimal and that she had requested to discontinue feeding and to leave the hospital on multiple occasions but had been persuaded to stay. It was confirmed that no facility in Ireland could meet Ms. M’s needs.Invocation of Wardship Jurisdiction
10.On 12 December 2019 Kelly P. appointed a guardian ad litemto Ms. M and ordered that a medical visitor’s report be prepared. On 17 December 2019 it was further ordered that Ms. M’s treating medical and nursing staff could detain her for the purposes of medical and psychiatric assessment and treatment. The order also permitted the use of reasonable force and restraint to enable that assessment and treatment.
11.On 21 January 2020 Prof. Cassidy reported that Ms. M continued to stabilise and gain weight but remained significantly underweight and required a continuation of treatment. She had refused NG feeding once but agreed to recommence it subsequently and continued variable compliance with exercise recommendations. She was reviewed by a specialist consultant psychiatrist, Dr. Giovanni Galavotti, from the Avalon Ward, Specialist Eating Disorders Inpatient Unit at Springfield Hospital, London on 7 January 2020 and was accepted for transfer. Prof. Cassidy noted that Ms. M had expressed that she did not wish to be treated at such a facility, but Prof. Cassidy reported that in his opinion Ms. M continued to lack capacity and requested an endorsement for continued treatment and to allow for her transfer to the specialist unit in the UK.
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