Hounslow CCG v RW

Summary[1]

In the sequel to the case of Re RW Hayden J had to consider what arrangements should be made for RW, a 78 year old with vascular dementia, many months after the Court of Appeal had upheld the conclusion that it was not in his best interests to continue to receive Clinically Assisted Nutrition and Hydration (CANH), via a naso-gastric tube (NG tube). Parker J concluded that it was not in his best interest and made a declaration to that effect.  RW had continued to live in his home, cared for by his youngest son, PT, almost single-handedly.  As Hayden J observed, "[e]very act of care has been an act of love and requires to be identified as such."  PT "strenuously objected to a regime that he regarded as slowly starving his father to death. This he sees to be the reality of the earlier court orders. For PT the preservation of his father's life is a moral obligation. It matters not, to him, that his father's condition is futile nor that the preservation of it may merely serve to continue pain. Since RW returned home to his son's care without any means of artificial nutrition or hydration PT has provided these by any means he could. He prepares small syringes of water, moist trifles, soft custard tarts which he considers his father enjoys. His objective is to keep his father alive."

The number of professionals admitted to RW's home began to fall away in May 2018 in circumstances where PW's conduct became increasingly intimidating out of his "stress, anxiety and […] fear for his father's survival."  The CCG became increasingly concerned about the management of RW's condition at home, and in January concluded that it would seek legal advice with a view to bringing the matter before the court, although

17. There then followed a period of significant and wholly unacceptable delay. Delay in bringing proceedings is far too common. It is entirely unacceptable and it is not to be tolerated. Delay is itself entirely inconsistent with the obligation on the CCG to protect RW's welfare interests. Urgent decisions need to be made today because RW's circumstances are so profoundly grave. I do not have the time to investigate the reasons for the delay in bringing this matter to court but I can say that there can be no justifiable reason for it.

An application came before the court in March, at which point the judge was primarily concerned about necrosis of RW's leg. "To her direct question (as I understand it) PT responded that about 10 days ago 'the leg detached completely' when he was turning his father. This was, to say the least, disturbing and shocking evidence. I have never heard of a situation like this and I sensed the doctors were equally alarmed. When I asked PT about it today, I was concerned that nobody had been able to identify where the leg is. PT told me he had wrapped it in cling film and put it in the freezer." When Gwynneth Knowles J heard this, it was not surprising that she decided that RW should be removed to hospital immediately.  He was admitted to hospital, where the doctors commented upon how well kept he was, and how well looked after; all were clear, however, that he had reached the very end of his life.

Against that backdrop, Hayden J had to determine what was in RW's best interests in endorsing a palliative care plan for him.  Hayden:

27. […] would very much have liked to have been able to endorse a plan which permitted RW to return home. There is no doubt at all, as the history of this case shows, that RW would want to die at home. I do not know whether he would survive the transition but I should have been prepared to take that risk. However, PT would, in my judgement, continue to try to give his father food and water. As I speak these words he indicates to me that this is precisely what he would do. I have been told by Ms I that, at this stage, if PT were to attempt to feed his father there is a real risk that he would asphyxiate on any food given. I cannot permit RW to be exposed to the risk of ending his life in this way and, if I may say so, I would not be prepared to take that risk for PT either, especially having regard to all the loving care he has provided for his father.
28. I endorse the applicant's plan. I indicate that it is in RW's best interest to have his sons with him as much as possible. I am not prepared to be prescriptive of the times and the circumstances in which the sons may visit. In this I reject the applicant's proposals in this respect.

Comment

Even in the summary form set out above, the facts of this case are stark, and (in a different fashion to the Rushton case also covered in this Report) show the emotional and physical consequences of familial care at the end of life.  At least some may be left with asking whether situations such as this are really best addressed in the courtroom, or whether the court is being left to pick up the pieces of jigsaw that were broken a very long time ago.

However, as with the PW case also covered in this Report, this case emphasises that where recourse to the court is required in the interests of the person, it is vital that it is not delayed.

[1] Katie Scott having been involved in the case, she has not contributed to this report.