Fitting contraceptive patch in best interests of woman with severe learning disabilities, court rules

An NHS trust can administer a contraceptive patch to a woman with severe learning disabilities who previously become pregnant after being raped, a judge has ruled.

In a Court of Protection hearing last week Mr Justice Cobb found in favour of the trust trialling a patch on the woman, named only as ‘Miss V’, for up to six months.

The trust said Miss V’s best interests would be served by providing her with contraception as an addition to an existing safeguarding package, a move supported by the local authority community learning disabilities team.

The Official Solicitor, acting on Miss V’s behalf, along with her mother, named as ‘Mrs W’, argued that the safeguarding plan was sufficient to protect her.

Miss V, who is 21, gave birth in 2016 to a child conceived in unknown circumstances and to an unknown father, possibly an acquaintance of one of her brothers.

The court heard that, following a brain injury sustained in a car accident when she was three years old, Miss V had no capacity to give sexual consent.

Justice Cobb said that he “wholly rejected” a submission by the Official Solicitor that by declaring contraception in her best interests he would be setting a precedent for other “vulnerable and incapacitous” women.

‘Extreme distress’

Miss V, who has an ‘understanding’ age of three to five years old, became pregnant in late 2015. Neither she nor her mother were apparently aware of the pregnancy until she was at about 28 weeks pregnant.

The court heard that Miss V, who was described as “extremely vulnerable but very sociable”, may have been sexually assaulted while Mrs W was away from the family home during an overnight hospital stay. After the birth Miss V’s baby boy was taken into foster care.

A local authority social worker told the court that Miss V had “no understanding as to who by, or how [she had got pregnant]”, could not comprehend why her body was changing and found even routine medical interventions traumatic.

“Though physically she healed well after [birth], the removal of the baby had a devastating effect on her emotional and psychological welfare,” the social worker said. “She could not understand where the baby was and was constantly asking for it; she was physically lashing out at her mother; she was self-harming; not sleeping; not eating.”

The social worker added that in 18 years of practice she had never seen such an “extreme level of distress”.

Safeguarding plan

After the birth, a safeguarding plan was put together, based on Miss V never being left in the care of “unknown and unapproved persons” nor allowed out of her home unaccompanied.

“The success of the plan, as a whole, depends heavily on high levels of cooperation between Mr and Mrs W and the local authority, monitored by announced and unannounced visits by professionals,” Justice Cobb noted.

The NHS trust initially applied for Miss V to be sterilised under general anaesthetic, but this course of action was no longer being pursued, the court heard. A community matron had in the meantime begun ongoing work with Miss V around sexual education and self-protection.

Justice Cobb said the safeguarding plan had been “broadly successful” but observed there had been a handful of lapses over the previous year. On some occasions Miss V had been left in the company of her brothers; on others she had managed to leave the family home.

“The underlying vulnerability of the plan is compounded by the fact Miss V shows limited recognition of danger, and [per the social worker’s evidence] ‘no understanding of the fact that she needs to be accompanied when out in the community or the reasons why this may be necessary’,” the judge said.

‘Dire consequences’

The local authority social worker warned the court that while the plan had been working, there would be “dire consequences” to Miss V’s psychological welfare were she to become pregnant again.

While Miss V had no capacity to give sexual consent, the court heard she had formed a limited understanding that wearing a patch would help prevent her having another baby.

According to the evidence of a consultant doctor, Miss V had expressed her views as wishing to avoid becoming pregnant again, and preferring the patch to surgery or other invasive procedures.

Justice Cobb said he was “not persuaded” that the absence of any further assault on Miss V revealed anything as to how much risk she might be at in future. Nor did he accept that giving her contraception might place her at greater risk of sexual exploitation.

“If this additional safeguard can be introduced without undue side-effects, and is a safeguard which Miss V is not unwilling to accept, then the best interests balance tilts in favour of its use,” said Justice Cobb in conclusion.

In light of the possibility that Miss V could experience side-effects from the patch, the judge ordered that the case be reviewed within a maximum of six months.