10. Mr A says the Trust administered lifesaving treatment without his informed consent. He says he had an advance decision not to receive lifesaving treatment which his GP witnessed in 2021. Mr A told us in the weeks prior to 3 May 2023 he had made the decision to stop taking insulin. He says it was not easy to do but he had a significant level of conviction and had planned his death. Mr A experienced a seizure and thought he was having a stroke so called an ambulance. He says he told the paramedics he had an advance decision and did not want to receive treatment.
11. Mr A says he told hospital staff about his advance decision, and staff gave him lifesaving treatment despite knowing he did not wish to receive it. Mr A says he was aware he was hooked up to a machine, but he took the machine’s beeping to mean he was dying and was happy to stay where he was. Mr A says he had capacity but did not give consent to receive treatment.
12. The paramedics report states ‘we discussed the advance decision with the patient around the seizures and Mr A agreed if we could not stop the seizures we could use medication to stop them. IV cannula sited for this reason.’
13. The Trust said Mr A presented to hospital via London Ambulance Service on 3 May 2023. Mr A had informed the paramedics about his advance decision. It says Mr A agreed to be brought to hospital where he was reviewed by a consultant in acute medicine in the Emergency Department (ED). The consultant confirmed Mr A did not refuse treatment while in the ED and did not refuse treatment while on the ward where Mr A was kept for overnight observation.
14. The records show the consultant took a history from Mr A. Mr A reported feeling weak at home and falling in the bathroom. Mr A reported stopping his insulin for the past two weeks with the intention of taking his own life. Mr A told the consultant he felt life was pointless. Mr A reported having a previous diabetic ketoacidosis in 2019. Mr A told the consultant he was currently prescribed Abasaglar.
15. The records show the consultant noted Mr A had an advance decision. The consultant noted they needed to act in Mr A’s best interests and given his low mood concerns and young age he would be for full CPR.
16. The consultant carried out a physical examination recording Mr A’s physiological observations including pulse, blood pressure, respiration rate, oxygen saturation, temperature and level of consciousness. The consultant carried out a neurological examination, observing the tone, power, coordination, sensation and reflexes of Mr A’s upper and lower limbs. The consultant observed Mr A’s speech, visual field and signs of facial droop.
17. The consultant requested blood tests to determine blood sugar levels and a CT head scan. The consultant diagnosed seizure episode likely caused by low sodium in the blood, in turn caused by excess water consumption and lack of salt intake. The consultant also diagnosed diabetic ketoacidosis (DKA) which is caused by poor compliance with insulin. The treatment plan comprised included administering IV fluids and long acting insulin, monitoring of potassium levels and venous blood gas.
18. A cannular was inserted into Mr A’s left arm and he was given 1 litre of saline to run over one hour and insulin at a rate of seven units per hour.
19. During the night the nursing notes state Mr A was mobile, self-caring and able to communicate his needs verbally. Mr A was discharged at 3.17am on 4 May 2023. The discharge summary confirmed the diagnosis and treatment of diabetic ketoacidosis.
20. The consultant confirmed no formal capacity assessment was carried out as it was felt Mr A had capacity at the time as he was alert, oriented and coherent although low in mood. The Trust says capacity is to be assumed and there was nothing to displace the presumption he had capacity. The Trust said Mr A also confirmed in his complaint he had capacity at the time.
21. The Trust said Mr A had capacity and could have chosen to refuse treatment which he did not do. It went on to say Mr A called the ambulance and agreed to go to hospital and was compliant with the treatment provided. It said when treating Mr A, the consultant would have explained the steps they were taking and checked Mr A was content, thereby obtaining consent.
22. S24 (1) of the Mental Capacity Act (MCA) 2005 states: ‘Advance decision means a decision made by a person after he has reached 18 and when he has capacity to do so, that if at a later time and in such circumstances as he may specify, a specified treatment is proposed to be carried out or continued by a person providing health care for him, and at the time he lacks capacity to consent to the carrying out or continuation of the treatment.
23. S25 (1) and (3) MCA 2005 further clarifies:
‘An advance decision does not affect the liability which a person may incur for carrying out or continuing a treatment in relation to a person unless the decision is at the material time valid, and applicable to the treatment. An advance decision is not applicable to the treatment in question if at the material time the person has capacity to give or refuse consent to it.’
24. NHS website states consent can be given verbally, for example a person saying they're happy to have an X-ray; in writing, for example signing a consent form for surgery; or given non-verbally as long as they understand the treatment or examination about to take place, for example holding out an arm for a blood test.
25. An advance decision is a valid document but could only be applied if Mr A did not have capacity at the time of treatment. Mr A confirmed himself he had capacity. In this case therefore, the advance decision was not applicable.
26. Mr A called an ambulance when he thought he was having a stroke. Calling an ambulance is a life-preserving act and not the action of someone who wants to die. We appreciate Mr A saying he did not know what to do in that moment as he had never experienced anything like it before. Mr A stated he wanted to die and had an advance decision, but his actions suggested he wanted to be helped.
27. The paramedic records state Mr A agreed they could use medication to stop the seizures and for this reason they inserted an IV cannula.
28. We have seen evidence the ED consultant considered Mr A’s advance decision but also considered Mr A had capacity to make decisions about his treatment rendering the advance decision invalid at that time in accordance with the Mental Health Act 2005.
29. We have seen no evidence in the records to suggest treatment was administered forcibly or against Mr A’s will or that Mr A refused the treatment being administered.
30. The records show Mr A was alert enough to hold a conversation with the consultant about his past and recent medical history and advise what medication he had been taking. Had Mr A wanted to refuse treatment it appears he had the capacity to do so.
31. The consultant carried out a number of examinations and tests including blood tests, a CT head scan and physical examinations. During this time Mr A had the opportunity to refuse treatment. Mr A would have cooperated with clinical staff to enable these tests and examinations to be carried out. Again, these are life-preserving actions. There is no evidence to suggest Mr A did not want to be examined and treated.
32. Mr A told us his express consent was not gained before treatment was administered. Consent can be gained non-verbally for example by holding out an arm to receive a cannular or have blood taken, as happened in this case. Mr A had blood taken and a cannular inserted. This would have required cooperation from Mr A, indicating he agreed with what was being done.
33. We have seen evidence the Trust considered Mr A’s advance decision. In accordance with the Mental Health Act, it administered care as Mr A had capacity to consent and at no time did he refuse any assessment, examination or treatment. We have seen no evidence the Trust administered treatment to Mr A against his wishes and will take no further action.