Authority to amputate

An update from a regular series written by Mr Robert Wheeler, director, department of clinical law, where he considers various aspects of clinical law that our nursing staff, medical staff and other professions rely on when caring for patients.

Regrettably, distal amputations of the lower limb due to vascular disease must frequently be performed. Seeking consent for surgery in the face of the refusal of amputation by incapacitated or vulnerable adults may be arduous for the patients, their families and clinicians, despite the early intervention of the local safeguarding services. In Kings College Hospital & LE [2025] EWCOP 46 (T3) unusual circumstances comprised a ‘tragic case’.

LE, 46, with longstanding diabetes and schizophrenia, has three children; the youngest is an infant. All her children are in the care of the local authority. Five months earlier, she had been admitted as an emergency suffering ketoacidosis, perhaps precipitated by a strangulated hernia. Following laparotomy she suffered a cardiac arrest, for which a noradrenaline infusion, amongst other treatment, was required. This led to gangrene of her fingers and toes. Three months later, still in hospital, her ischaemic tissue remained persistently infected, despite conservative treatment. Her left hand was ‘...completely non-functional, with fingers and thumb stiff, immobile…’ lacking sensation. Her right hand ‘…retains a very limited pinch and grab function, insufficient for self-care or fine motor tasks. As a result, she requires assistance with feeding, dressing and hygiene.’ Her necrotic toes on both feet lacked sensation, so were prone to injury.

It became clear that she would require multiple digital amputations. Notwithstanding LE’s lack of capacity to make decisions about treatment, she refused surgery when these matters were addressed during multiple discussions and became increasingly frustrated at having to remain in hospital. Following a ‘best interests’ meeting, the hospital made an urgent application to the court to determine whether it was lawful to deprive her of her liberty and proceed with the surgery in these circumstances.

Evidence from a plastic surgeon revealed the ‘many discussions’ relating to proposed surgery, noting that the ‘precise extent would be dependent on intraoperative findings… but it was anticipated that the left hand amputations would be through the metacarpophalangeal joints, some of the palm, and most of the left thumb.’ Flap reconstruction from another site to cover the exposed bone on the left hand was considered, but the surgeon concluded that due to the high degree of care required for postoperative flap management, local skin grafting was a more realistic option. On the right hand, the fingers and thumb would need to be removed at the distal interphalangeal joints, to be covered by adjacent tissue. The extent to which the toes on both feet were resected would depend on clinical necessity. The court was told that ‘…providing there were no wound complications the recovery plan is not overly onerous, and it was …unlikely that LE would need significantly more care than she had previously…although hand therapy would be required post operatively’.

Evidence from a psychiatrist revealed that LE expressed ‘unusual and inaccurate beliefs’ concerning her necrotic digits; that in different ways, her hands and feet had become infected after exposure to dirt…which could easily be washed off, without other intervention. For this reason, LE requested discharge, and advice from a chiropodist by way of treatment.

The court recognised that ‘…LE’s feelings have remained consistent in opposition’ to amputation but equally accepted the evidence that her views were irrational. However, the judge accepted that LE recognised and understood that it was the court that was making the decision. The hospital’s application to operate was granted, on the basis that further delay would not be in her best interests.

Behind every case where an incapacitated patient refuses amputation lies a unique set of facts. If these cannot be resolved with the assistance of the local adult safeguarding services in a timely fashion, please seek legal advice.

Mr Robert Wheeler
Department of clinical law
October 2026