MCA case study - 69 year old male

Produced by: NHS London Purchased Healthcare Team

Background summary

Patient B was a 69-year-old male who had been acutely unwell with Pulmonary embolism x 2 and had required a stay in the local ICU for treatment. He lived alone and had no family members or significant friends.

Following his move from ICU to an acute bed he became resistive to care procedures stating staff were continually interfering with him and repeatedly asking to go home. He was taking all prescribed medication whilst in hospital including anti-platelet medication which had been medically determined as necessary to reduce any further risk of an embolism. B was considered high risk for further embolisms due to his medical history and previous lifestyles.

Upon discharge B, was still taking his anti-platelet medication but when seem by the GP within 3 days of discharge refused to take it any longer. The GP advised B of the significant risks to his life if he did not take the medication but B continued to refuse saying it was his choice and he choose not to take it. B also suffered from long-term Paranoid Schizophrenia and was under the care of a local psychiatrist. The GP asked the psychiatrist to undertake an urgent assessment for possible detention and treatment under the MHA and also whether B had the capacity to refuse to take anti-platelet medication. The Psychiatrist concluded following assessment that B did not meet the criteria for detention or treatment under the MHA, but he considered at the time of assessment that B did not have the capacity to provide informed consent to take the medication required for his medical condition.

The GP contacted the CCG adult safeguarding lead for advice saying he believed there was a significant risk to the patient that could result in their death if they did not take the medication.

The safeguarding lead advised the GP:

  1. That he would have to undertake the mental capacity assessment regarding the taking of medication as he was the decision maker for the treatment as the prescribing medical officer. The GP was also advised as he would need to take into account the views of the psychiatrist and treating physicians when making his determination and any subsequent Best Interest Decision.
  2. As the patient had no relatives, next of kin or significant friends to involve in the decision making process an urgent referral to an IMCA was required as an independent advocate for the patient. 
  3. The GP would need to ensure sufficient time was taken over the assessment and to ensure the patient was involved as fully as possible in the decision making process. 
  4. If following assessment, the GP as decision maker concluded that the treatment was necessary in the patients Best Interest and the patient lacked capacity to give informed consent an application to the Court of Protection would be made. 
  5. It was further concluded that if the patient did require the treatment for which he was refusing it was likely that any medication given would require the use of restraint to administer it safely. There was a significant doubt whether district nurses would agree to using such restraint or that they had sufficient skills and expertise to administer medication whilst using restraint safely.
  6. In such circumstances the Best Interest decision would also need to take into account the amount of restraint that might be required and whether such a degree of restraint would be in keeping with least restrictive, for the least amount of time, proportionate and not amount to a deprivation of liberty in keeping with the MCA. If this seemed unlikely that then the Court of Protection would be asked if necessary to authorise B’s removal from his home to a nursing home placement where staff could administer the medication using restraint if necessary and deprive B of his liberty by refusing to allow him to leave if he so attempted.
  7. The GP was advised to ensure his records were comprehensive as was his capacity assessment and Best Interest decision making process which all showed a due regard to the principals of the Act and Best Interest checklist.

The GP and IMCA saw the patient on 3 separate occasions and concluded the patient did have the capacity to make his own decision regarding the medication. When the risks of not taking the medication were fully explained and possible consequences for not taking made clear, the patient agreed to take medication. The GP used the opportunity to gain the patients agreement for referral to social services for a community care assessment with a view to a home care support package and increased socialisation. The psychiatrist increased his review appointment to ensure the patient’s mental state remained stable to minimise the risk of non-compliance.

Learning points

  1. The GP initially considered as the psychiatrist had undertaken an assessment it was sufficient to base a Best Interest decision on that assessment and therefore he did not need to carry out a formal assessment himself.
  2. The GP surgery had no specific forms or documentation for recording capacity assessments and Best Interest decisions
  3. The GP did not know what the role of the IMCA was or how to contact them, or that to administer medication without the patient’s consent in the circumstances where a high level of restraint might be required would be likely to need the intervention of the Court.
  4. It is likely that when time was taken to provide the patients with all the facts and consequences associated with the intended treatment he was more amenable to treatment and able to make an informed decision.

About this case study collection

Purpose: The purpose of this document is to share MCA cases that have taken place within London for NHS staff to refer to when dealing with difficult MCA cases.

Audience: Commissioner and Provider staff involved with MCA decision making.

Background: The London NHS Commissioner MCA Board identified a number of tools/documents to support them to gain MCA assurance. One of the requests was to share MCA case studies. This document outlines a number of MCA cases which has been shared by CCG and provider MCA leads across London.

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