Capacity Assessment – decisions about care

*All names, initials, and other potentially identifying details have been changed in the
interests of confidentiality for the person involved and their family*

We are often asked to assess people’s mental capacity to make decisions. Under the Mental
Capacity Act (MCA) 2005, people are assumed to have the ability to make decisions about
their life, but if they experience brain damage such as from a brain injury or stroke, this can
affect their cognitive (thinking) abilities and lead to their capacity for decision-making to be
questioned. Decisions frequently have legal implications, for example if someone needs to
write or change their Will, or decide where they want to live.

In this case example, I was asked to assess a 59-year-old man, Martin, who had had a
severe traumatic brain injury (TBI) due to a road traffic accident 20 years previously. The
brain injury had caused a range of physical and cognitive difficulties for Martin, such that he
needed carers alongside him day and night to attend to his personal care and support him
with other activities of daily living. A change to his care team was proposed by Martin’s
family, from a generic care agency to one specialising in neurological conditions. Martin’s
Case Manager instructed us to assess whether Martin wished to change his care team, and
indeed whether he had the mental capacity to make this decision.

Martin’s communication was significantly affected by his brain injury. This made the
assessment challenging as he could not communicate his wishes through spoken language,
nor could he understand spoken or written language. I needed to base my assessment on
behavioural observations of Martin during our discussions, and on information from his
family and carers to gain an understanding of his needs and likely preferences. This included
finding out about Martin’s personality and his likes and dislikes before his TBI.

My assessment indicated that Martin did not have the mental capacity to make decisions
about his care. In such cases, the MCA states that legally those making decisions on behalf
of a person lacking capacity must act in their best interests. It was decided that given the
new care team had more specialist training and experience in working with people with brain
injuries, and given the complexity of Martin’s current needs, it would be in his best interests
to receive this higher level of specialist care.

Dr Laura Meader, Clinical Neuropsychologist