The limits of autonomy: What ICBs can learn from Patricia’s case

On 31 July 2025, the Court of Protection handed down a landmark judgment in the matter of Patricia, overturning previous orders that had had the effect of preventing clinicians from administering compulsory treatment under the Mental Health Act to a young woman with severe anorexia nervosa (AN), autism, and pathological demand avoidance (PDA). The case has key takeaways for Integrated Care Boards (ICBs), particularly in relation to commissioning responsibilities, risk management, and collaborative care planning.

Mills & Reeve acted for Norfolk and Waveney Integrated Care Board. 

Summary of the judgments

Patricia, a young woman aged 25, had been subject to final orders following Court of Protection proceedings that were made in 2023 by Mr Justice Moor. These orders prioritised her autonomy and prohibited forced treatment against her will, despite her being assessed as lacking capacity to make decisions about her treatment. Despite her strong will to live, her cognitive impairments, driven by AN and PDA, prevented her from accepting the calories needed to survive.

In May 2023, the Court ordered that:

• It wasn't in Patricia’s best interests to receive nasogastric (NG) feeding under restraint or any other medical treatment against her wishes
• Patricia was to be given autonomy to decide whether to gain weight

In October 2023 the matter returned to Court and the order was extended to all hospital admissions, effectively barring future compulsory treatment under the Mental Health Act.

These orders were made in the context of Patricia’s temporary improvement in caloric intake and her expressed desire to recover voluntarily. However, by 2025, her condition had deteriorated significantly. In 2025, the Court of Protection found that the autonomy granted had placed an impossible burden on Patricia, one she could not overcome due to the cognitive effects of her conditions.

In March 2025, nearly 18 months after the October 2023 orders, an urgent application was brought by her family which sought to discharge the 2023 declarations, which had given Patricia autonomy over her treatment decisions, to enable clinicians to treat Patricia, including potentially using NG feeding under restraint, and to allow Patricia to access treatment in a specialist eating disorder unit (SEDU), which was not possible under the existing orders because many SEDUs wouldn't admit her while those orders remained in place. 

In the anticipated judgment handed down on 31 July 2025, Mrs Justice Arbuthnot concluded that: 

• She should revisit the 2023 orders made by Mr Justice Moor because Patricia’s condition had significantly deteriorated, the original orders had become an impossible burden preventing access to potentially life-saving treatment, and new evidence and circumstances not covered in the earlier judgments justified a fresh determination in Patricia’s best interests.
• Patricia lacked capacity to make decisions about her treatment.
• The 2023 orders had placed an impossible burden on her to consent to treatment her illness would not allow.
• The hands-off approach had failed, and Patricia was now closer to death than in 2023.
• Lifting the orders made in 2023 was in her best interests, allowing clinicians and SEDUs to consider treatment options without legal barriers.  

Implications for ICBs

1. Commissioning: ICB’s should be prepared to commission bespoke, flexible care packages when SEDU admission is not immediately possible. In Patricia’s case, significant special adjustments were made for Patricia in light of her diagnoses - the ICB commissioned additional 24-hour care a day, a dongle so that Patricia could access online resources, a food card so that she could buy her own food and specialist psychological support. In addition to the adjustments made for Patricia by the hospital, the Judge commented “it was hard to imagine how Patricia could have been better cared for in these difficult and sad circumstances.”
2. Legal awareness: The 2023 declarations created a barrier to treatment that is open to most other AN patients. The ICB’s position in 2025 was cautious, recognising the risk of psychological harm if the orders were lifted, but also the risk of death if they remained in place.
3. Collaboration: The judgment details the extent of multi-agency collaboration between provider collaboratives, acute hospitals, mental health trusts, SEDUs and ICBs in managing high-risk AN patients.

Further reading

Mills & Reeve’s 2024 blog, Whose voice should be the loudest?, explores the ethical and legal tensions in cases like Patricia’s, where courts have upheld the right to refuse life-saving treatment. It raises critical questions about autonomy, oversight, and the role of professionals in safeguarding life.

You can read the full judgment here.

Final thoughts

Patricia’s case is a powerful reminder of just how complex and challenging it can be when an individual with severe mental illness refuses treatment and the balancing act between autonomy and capacity to make decisions.

For ICBs, it highlights the importance of being flexible in how care is commissioned and the requirement to make reasonable and special adjustments, staying informed about the legal landscape, and working closely and compassionately with partners across the system, including the person at the very centre. Ultimately, it’s about making sure the system can support those who are most vulnerable by ensuring that legal, clinical, and ethical considerations are balanced with compassion, adaptability and the patient’s best interests at the centre of decision making. 

Neil Ward, Leah Selkirk and Isobel Matthews were instructed by the ICB in this case. If you require support, please get in contact with the team.