The Court of Protection (CoP) was faced with a difficult question regarding whether a Caesarean section (C-section) against the mother's wishes was in her best interest due to her mental health.
Background:
SC, a 37-year-old woman who had already given birth twice via C-sections, was pregnant with a due date of 22 November 2024. She has previously been detained under the Mental Health Act (MHA) 1983 in 2019 and 2021. In January 2024, she suffered a miscarriage and fell pregnant in the following months. On 26 September 2024, SC was again detained under s.2 of the MHA 1983. On the 22nd of October, she was detained under s.3 MHA, diagnosed as suffering from mania with psychotic symptoms. The next day, an ultrasound scan showed evidence of static foetal growth leading the medical team to request the C-section to be moved to no later than the 4th of November. There were various medical reasons for the urgency of the proceedings initiated by the NHS Trust, one being the concern that SC’s mental health had been deteriorating.
Although the scan demonstrates she was carrying one child, she believed she was carrying four small babies. She also believed that, with a C-section, her other three babies would be sold. She maintained she wanted a natural birth despite the risk of uterine rupture due to her two previous C-sections. SC was also not made aware and did not have a chance to discuss the application until a day before the hearing.
Decision:
The CoP decided that it was in P’s best interest to have the planned C-section. Mr. Justice Cusworth took his time in analysing all the legal principles but also the arguments and evidence of each side. He first started by determining whether SC had the capacity to make the required decision by following the steps set out by MacDonald J in North Bristol NHS Trust v R [2023]. He used the Court of Appeal’s decision in relation to Hemachandran v Thirumalesh [2024] that, “where there is objectively verifiable medical consensus as to the consequences of not having medical treatment if a person does not believe or accept that information to be true, it may be that they are unable to understand it and/or unable to weigh it for the purposes of the MCA.”
The Judge spent some time discussing the prospect that SC’s psychiatric conditions would worsen if she had to undergo a C-section against her will. There was evidence of an increased risk of deterioration of her mental health during the postpartum period and upon her discovery that she had only delivered a single baby.
In the end, Mr. Justice Cusworth was persuaded that SC was not able to make a decision due to her delusional beliefs and that her views were unduly influenced by her mental illness. He concluded that the benefit of a C-section outweighed the risks of deterioration to her mental health. The fact that the local authority had planned to make an application for the removal of the baby also played a role, as the Court noted that “any attempt at vaginal delivery, aside from being fraught with medical risk, may also be the cause of further trauma for SC if, even after coming through that procedure successfully for the first time, she is nevertheless unable ultimately to care for her child.”
Implications:
This case demonstrates the difficult position in which courts might be placed and the delicate balancing exercise they have to undertake. The judgement emphasises the serious nature of the decision and the interference it makes on the personal autonomy of SC. However, the weight of evidence was overwhelming in precluding the mother’s wishes from being taken into consideration.