​Declaration regarding capacity and orders for serious medical treatment relating to the P, a woman who was in the advanced stages of her pregnancy, were made.

Application by the Trust for permission to amputate the P's leg was granted.

The court had to decide whether the assessment of capacity to make decisions about diabetic management is one macro-decision which encompasses all of the many micro-decisions that the P is required to make when managing her diabetes, or, whether the P's capacity should be assessed in respect of each micro-decision or group of micro-decisions.

The P is a 64-year-old woman with a personality disorder with components of different types and has an emotionally unstable paranoid histrionic and dependant personality disorder. She also suffers from a number of physical health conditions, including hypertension, chronic obstructive pulmonary disease and unstable diabetes, which has led for instance to her having a below-the-knee amputation. Generally, she is compliant in the administration of the insulin, but not compliant in relation to other forms of medication. The management of her healthcare has been increasingly very difficult. Over four days in June 2018, Cohen J heard several applications concerning the P, concerning her capacity to make decisions about her residence and care. There are occasions when the P has the capacity to make micro-decisions in respect of her diabetes and occasions when she does not, i.e. that her capacity fluctuates. This hearing was to determine whether, when deciding if the P has the capacity to manage her diabetes, this is to be considered as one macro-decision, a series of micro-decisions which need to be made on a regular ongoing basis, or as a group of decisions.

The court approached the matter on the basis of the experts' conclusions, logically, legally and practically, and concluded that it was a macro-decision, and the P lacked capacity to take the macro-decision. The issue of fluctuating capacity, therefore, simply did not arise.

Read the full text of the judgment on Bailii