This blog will take a dive into the decision in the case of King’s College Hospital NHS Foundation Trust v LE (by her litigation friend, the Official Solicitor) [2025] EWCOP 46; a case where the King’s College Hospital NHS Foundation Trust (KCH) made an application to the Court of Protection for authority to amputate necrotic tissue from LE.
This case takes a focus on the test for best interests of LE.
The material facts
LE was a 46 year old woman with schizophrenia and diabetes and had been an inpatient at KCH since early July 2025. She was admitted after having been found incontinent and confused. Following her admission, she was diagnosed with diabetic ketoacidosis and a strangulated hernia and required surgery.
After the surgery, LE suffered a cardiac arrest and required admission to the ICU. Whilst in the ICU, LE received medication to preserve her major organs which led to ischaemia and gangrene in her extremities. This affected all of her fingers and thumb on her left hand, the tips of her fingers on her right hand and varying levels of necrosis on her toes. This resulted in her left hand being completely non-functional and her right hand being extremely limited in its functions.
LE requires assistance with feeding, dressing and hygiene and has consistently refused to agree to amputation on the basis that she believes the infections would recover.
In a meeting on 7 October 2025, two options were discussed: amputations or for LE to be discharged. Despite many discussions with clinicians, LE refused to agree to the amputations.
LE was assessed as lacking capacity on 21 October 2025 and a deprivation of liberty authorisation was enacted on 3 November 2025. On 6 November 2025, KCH brought an application for amputations and reconstructive surgery of LE’s hands and feet.
The legal framework
When making a decision, the Court of Protection has to consider the Mental Capacity Act 2005. This means that the Court has to make decisions in the protected party’s best interests. This is determined by considering all aspects of the party’s position, not just the medical position. The Court has to consider all of the following so far as is reasonably ascertainable:
- The party’s past and present wishes and feelings;
- The beliefs and values that would likely influence their decision if they had capacity;
- Other factors that they would likely consider if able to do so;
- Medical benefits and risks; and
- Quality of Life.
Using these criteria, the court has to balance the risk v reward of making a decision in favour either way. In LE’s case, the court considered her strong opposition to surgery, her relationship with her daughter, her desire not to die, the clinical risks and the practical realities of recovery and rehabilitation. LE’s opposition was consistent and heartfelt. The Judge acknowledged that a person’s wishes and feelings must always be taken seriously. However, the court found that LE’s refusal was founded on irrational beliefs rather than a reasoned assessment of risk. Applying the test set out in the case of Re M, ITW v Z [2009] EWHC 2525(COP), the court gave her views limited weight. This was because the Court considered that the more a view is driven by delusion and the less the person can weigh information, the less decisive that view can be in the best‑interests balancing exercise, especially where life‑threatening risks loom.
The decision
The Court decided to authorise for surgery to be carried out on LE to remove the gangrenous fingers and toes, despite her opposition to the surgery. They reached the decision on the basis that it was in LE’s best interests to do so. Mrs Justice Theis considered that the factors that weighed in favour of permitting the surgery were as follows:
- Presumption to preserve life – LE had told the Judge that she did not want to die and this had been consistent with what LE had told others prior to the hearing. When considering this alongside the medical evidence from an expert, who advised that without surgery, there was a very high risk of infection and sepsis. This risk increases amongst patients with diabetes, which LE also had.
- Wishes and feelings of LE – The Judge found that some of the wishes were founded on an irrational basis, including the belief that LE considered she could wash off the necrotic tissue.
Mrs Justice Theis stated that: ‘Having carefully considered the evidence and balanced the competing best interest considerations regarding the options before the court I am satisfied it is in LE’s best interests for this application to be granted and for what is now a detailed care and treatment plan, submitted by the parties at the conclusion of the hearing, to be approved. Whilst I have carefully and fully considered LE’s wish for there to be a further delay for her ‘alternative’ plan to be looked at, I accept Dr X’s evidence that there is nothing to be gained by any further delay. On the contrary, in my judgment, further delay would be contrary to LE’s best interests due to the risks, in particular of infection. The court can be confident the dedicated clinical team are wholly committed to taking all steps possible to mitigate any distress LE will feel when informed of the decision and what lays ahead for her. Their level of support and expertise to date demonstrates their commitment to do all they can to make this difficult procedure and post operative recovery take place with LE’s best interests at the core of any decision they make.’
Summary
The Court of Protection authorised the proposed amputations and reconstructive surgery for LE, finding that these interventions were in her best interests under the Mental Capacity Act 2005. The decision was driven by clear clinical evidence: without surgery, LE faced a high and imminent risk of infection, sepsis and death, while conservative management had already failed. Although LE’s opposition was consistent, it was rooted in delusional beliefs and therefore carried limited weight in the best-interests analysis.
The judgment reaffirmed established principles rather than creating new law, but it illustrates how courts balance autonomy with protection when incapacity and urgent medical risk conflict. Ultimately, the court prioritised preserving life and enabling rehabilitation, while ensuring that LE’s dignity and values were considered throughout the process.
This case serves as a reminder that best-interests decisions are holistic, fact specific, person-centred and often require swift action to prevent catastrophic harm.
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Giacomo Ciccognani is a solicitor in our expert Dispute Resolution team.
If you have concerns about the above subject, please contact Giacomo or a member of our expert team in Derby, Leicester, or Nottingham on 0808 239 3916 or via our online enquiry form.
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