Endorsement

Overview

The appellant, L.H., appeals from a decision of the Consent and Capacity Board (the “CCB”) dated May 21, 2024, which confirmed the finding of the respondent, Dr. Jeanetta Viljoen, that L.H. was incapable of consenting to treatment with antipsychotic medication. The CCB also confirmed L.H.’s involuntary status, but that decision is not appealed. The specific issue in this appeal is whether L.H. had the ability to appreciate the reasonably foreseeable consequences of consenting to, or refusing, treatment with antipsychotic medication.

Background

L.H. was 55 years old at the time of the hearing before the CCB. She holds a PhD in educational leadership, and has had a long and successful career as an educator, including as a professor.

L.H. has scoliosis, kyphosis and congenital hearing loss, and uses a walker. Prior to her current admission to Joseph Brant Hospital, she lived in an apartment in a senior living home with comprehensive supports.

L.H. has a psychiatric history of more than ten years with persecutory and paranoid delusions. She has had multiple mental health apprehensions and hospitalizations, and many incidents of police involvement.

L.H. believes that one of her former students, E.G., was interested in her romantically and followed her. Collateral information obtained by Dr. Viljoen indicates that L.H. has been fixated on E.G. since 2016, and has received at least 25 cautions from police due to her behaviour with respect to her delusions regarding E.G. Among other things, she reported E.G. to the FBI, accusing him of threatening to kill President Obama, President Bush, and Prime Minister Trudeau. In October 2022, L.H. was charged with criminal harassment of E.G.

Between October 22, 2019 and September 28, 2020, L.H. was dispensed olanzapine, an antipsychotic medication she had been prescribed during a hospitalization in 2019. Dr. Viljoen indicated that L.H.’s records document clear improvement in L.H.’s mental state while taking olanzapine, including a decrease in her persecutory and paranoid delusions, and a decrease in her obsession with E.G. During that time, her engagement with police decreased substantially. Her engagement with police increased after September 28, 2020.

L.H. has received police cautions not to have contact with multiple neighbours, police members, Oakville town council, and community members. She has had 178 police occurrences. In the majority of them, she is the complainant.

On May 9, 2024, L.H. was admitted involuntarily to Joseph Brant Hospital on a Form 1, due to concerns about her mental health. A nurse noted L.H. had increased paranoia and delusions, and an escalation in paranoia and accusations against E.G. In addition, L.H. was hearing voices and responding to them.

On May 12, 2024, L.H. was assessed by Dr. Bawks, a psychiatrist at Joseph Brant Hospital. Dr. Bawks found that L.H. was not capable of consenting to treatment, and that she met the criteria to be admitted to hospital as an involuntary patient. The following day, L.H. applied to the CCB for a review of her finding of incapacity and to review her involuntary status.

On May 13, 2024, L.H. was seen by Dr. Van Impe for a psychiatric consultation. Dr. Van Impe opined that L.H. had a mental disorder with very severe delusions. L.H. denied any mental illness. She told Dr. Van Impe to make a police report and get a warrant for E.G.’s phone. Dr. Van Impe found L.H. was clearly incapable of consenting to her own treatment, and had “zero insight into delusions and the impact they hold on her behaviour.” Dr. Van Impe concluded that L.H. did not appreciate, understand, or believe that antipsychotic medication could be of any potential benefit to her because she denied any mental disorder that could respond to antipsychotic medication.

On May 14, 2024, Dr. Viljoen became L.H.’s attending physician. They met on May 14, 2024. During their conversation, L.H. repeatedly insisted Dr. Viljoen report E.G. to the police for sexual harassment. She alleged E.G. was grooming children, using “military-grade broadband” to harass her, and indicated that she believed the police were friends with E.G. and protecting him.

Dr. Viljoen asked L.H. about threatening voicemails she had left for the head of security at Joseph Brant Hospital. L.H. denied leaving the messages and said it was “AI.” She has asserted at other times that the head of security at Joseph Brant Hospital is E.G.’s girlfriend.

Dr. Viljoen concluded that L.H. was incapable of consenting to treatment.

The CCB Hearing

In the documents Dr. Viljoen submitted to the CCB, she states that the finding of incapacity was made by Dr. Bawks on May 12, 2024. However, because Dr. Viljoen had become L.H.’s attending physician, she was the attending physician at the CCB hearing.

Dr. Viljoen delivered a document package to the CCB, including a Consent and Capacity Board Summary for Incapacity to Consent to Treatment, and documentation excerpted from L.H.’s clinical records. Dr. Viljoen gave no oral evidence in chief, but answered questions from L.H.’s counsel and the CCB. L.H. also gave evidence at the hearing.

The CCB Summary for Incapacity to Consent to Treatment was included in the document package for the CCB. It indicates that the plan of treatment for L.H. is treatment of psychosis with antipsychotic agents, oral or injectable.

The CCB summary indicates that the evidence that L.H. is unable to appreciate the reasonably foreseeable consequences is:

[L.H.] does not acknowledge any mental health symptoms of psychosis. She therefore cannot apply information provided to herself. She does not appreciate potential benefits of treatment.

The document package to the CCB also included Dr. Viljoen’s consultation notes of the May 14, 2024 meeting (dated May 16, 2024). The notes with respect to the mental status exam Dr. Viljoen undertook of L.H. state:

Her mental status is significant for clear psychotic symptoms. She is overinclusive, thought disordered, demonstrates clear persecutory delusions. She also has narcissistic traits. Her speech is pressured difficult to interrupt, but certainly not rapid. There is no evidence of mania. No evidence of objective depression. She is overinclusive, describes psychotic symptoms in the form of delusions as noted, as well as symptoms suspicious for Capgras delusions and auditory hallucinations. She demonstrates no insight into her current mental health symptoms, and her judgment and impulse control appear to be poor.

She has been informed of her diagnosis of psychosis and treatment suggestions for antipsychotic agents. She is provided with written information regarding aripiprazole as well as paliperidone, and I have reviewed potential side effects with her. She adamantly denies any psychotic symptoms and is refusing to take any antipsychotic agents.

She is incapable to consent to treatment of psychosis with antipsychotic agents, largely on the basis that she does not acknowledge any psychotic symptoms, and as such cannot apply information provided to herself. She does not appreciate the potential risks or benefits of treatment decisions.

The CCB Decision

The CCB instructed itself that the onus of proof to establish incapacity to consent to treatment under the Health Care Consent Act, 1996 always lies on the attending physician, on a balance of probabilities. It noted that it must be satisfied on the basis of clear, cogent and compelling evidence that the physician’s onus has been discharged.

The CCB directed itself to consider all of the evidence properly before it, including hearsay evidence which it noted it may accept and consider, but had to carefully weigh.

With respect to the question of capacity to consent to treatment, the CCB noted that s. 4(2) of the HCCA presumes a person to be capable to consent to treatment and places the onus to establish otherwise on the health practitioner.

The CCB set out the test for capacity to consent to treatment in s. 4(1) of the HCCA, which provides that a person is capable with respect to a treatment if the person is able to understand the information that is relevant to making a decision about the treatment and able to appreciate the reasonably foreseeable consequences of a decision or lack of decision.

The CCB noted that Dr. Viljoen was relying only on the second branch of the test to establish incapacity to consent to treatment. It thus asked itself whether the evidence established that L.H. was able to appreciate the reasonably foreseeable consequences of a decision or lack of decision about the proposed treatment.

The CCB noted Dr. Viljoen’s evidence that she had last assessed L.H. on the day of the hearing and stated she would continue to find L.H. incapable. Dr. Viljoen’s evidence was that L.H. has a diagnosis of psychosis, with symptoms including thought disorder, persecutory delusions and auditory hallucinations. Dr. Viljoen testified that L.H. was unable to acknowledge the possibility of either having a mental condition or any symptoms. In Dr. Viljoen’s view, L.H. was unable to pass the second branch of the capacity test because she had anosognia, or lack of insight into her condition.

The CCB referred to Dr. Viljoen’s evidence that she had reviewed the diagnosis, symptoms and treatment with L.H., as well as the side effects of treatment. The CCB also noted her evidence that she had explained to L.H. that previous treatment with olanzapine had resulted in her phone calls to police declining, but L.H. was unable to acknowledge any change in her mental condition while dispensed olanzapine. L.H. believed that olanzapine had been prescribed to help her with sleep.

The CCB referred to L.H.’s evidence denying that she was psychotic or had delusions or hallucinations, and that she denied the possibility that her beliefs could be related to a mental condition.

While accepting that L.H. testified to the best of her ability, the CCB indicated that where her evidence conflicted with the evidence of Dr. Viljoen, it preferred the evidence of Dr. Viljoen. It noted that at times, L.H.’s testimony reflected some of the symptoms identified by Dr. Viljoen, including her thought disorder and delusions about E.G. The CCB concluded that L.H. was “wholly unable to consider the possibility that she had a mental condition or that she was possibly affected by the manifestations of such.” It found it “compelling that L.H. was unable to appreciate any change in her condition with treatment despite documentation to the contrary.” The CCB determined that L.H.’s mental condition prevented her ability to consider the reasonably foreseeable consequences of a treatment decision, and confirmed the finding of incapacity regarding antipsychotic medication.

Issue

The question on this appeal is whether the CCB erred in confirming Dr. Viljoen’s finding that L.H. was incapable of consenting to treatment. To answer it, I must determine the following issues:

a. Did the CCB err in finding the respondent satisfied her onus when there was no direct evidence about L.H.’s ability to appreciate the reasonably foreseeable consequences of a decision or lack of decision?

b. Did the CCB err in finding the respondent satisfied her onus when there was no evidence that any information had been given to L.H. about the benefits of the treatment or the foreseeable consequences of a decision regarding it?

c. Did the CCB err in finding the respondent satisfied her onus, because there was no corroboration of the doctor’s evidence of incapacity?

Analysis

Preliminary Issue: Anonymization

L.H. seeks an order anonymizing these reasons.

Confidentiality and sealing orders and related publication bans are governed by a discretionary test that balances the public interest in open courts with other public interests that the open court principle may compromise. As the Supreme Court of Canada described in Sherman Estate v. Donovan, 2021 SCC 25, at para. 38:

In order to succeed, the person asking a court to exercise discretion in a way that limits the open court presumption must establish that:

(1) court openness poses a serious risk to an important public interest;

(2) the order sought is necessary to prevent this serious risk to the identified interest because reasonably alternative measures will not prevent this risk; and,

(3) as a matter of proportionality, the benefits of the order outweigh its negative effects.

All three prerequisites must be met before a protective order can be made: Sherman Estate, para. 38.

In this case, court openness poses a serious risk to an important public interest, that is protecting the privacy of a person who is engaged in proceedings regarding their capacity to consent to treatment with antipsychotic medication. An unnecessary intrusion into L.H.’s privacy may discourage others from either seeking treatment, or appealing an order requiring them to have treatment, if their identifiable personal health details are publicly disclosed. In this case, L.H. has also published academic literature that she does not wish to see unjustifiably discredited by any association between her mental health and her body of work.

The order sought is narrow and tailored: L.H. seeks only anonymization in these reasons. The public is still able to access these reasons and understand the process of the court. The only thing they are prevented from knowing is L.H.’s name.

I find that the benefits of the anonymization order are significant. The deleterious effects are minor.

I thus grant the anonymization order.

Standard of Review

As a statutory appeal, the appellate standard of review applies. Questions of law are reviewed on a correctness standard, while findings of fact may only be overturned where there is palpable and overriding error: Canada (Minister of Citizenship and Immigration) v. Vavilov, 2019 SCC 65, at para. 37; Housen v. Nikolaisen, 2002 SCC 33.

As the Court of Appeal held in B.L. v. Pytyck, 2021 ONCA 67, at para. 22:

The Board’s identification of the proper statutory test for capacity involves a question of law reviewable on the correctness standard. The Board’s application of the statutory test for capacity to the evidence to determine whether a person is capable is a question of mixed fact and law, reviewable on the deferential standard of palpable and overriding error, absent an extricable question of law in the Board’s analysis: Starson v. Swayze, 2003 SCC 32, para. 84; Gajewski v. Wilkie, 2014 ONCA 897, para. 33.

Legal Principles Relevant to Capacity

In Starson v. Swayze, 2003 SCC 32, the Supreme Court of Canada considered the test for incapacity in s. 4 of the HCCA. At para. 13, the Court summarized four important points:

a. The person is presumed to be competent and the standard of proof for a finding of incapacity is a balance of probabilities;

b. The test relates to the capacity or ability to understand and appreciate, not actual understanding and appreciation;

c. The first component of the test for capacity is that the person be able to understand the information that is relevant to making a decision about the treatment at issue;

d. The second component of the test is that the person be able to appreciate the reasonably foreseeable consequences of a decision or lack of decision.

As I have noted, it is the last of these points that is in issue in this appeal.

Of the ability to appreciate the reasonably foreseeable consequences of a decision or lack thereof, the Supreme Court of Canada wrote in Starson, at para. 18, that three common clinical indicators of a person’s ability to appreciate the consequences of accepting or declining treatment are: (i) whether the person is able to acknowledge the fact that the condition for which treatment is recommended may affect him or her; (ii) whether the person is able to assess how the proposed treatment and alternatives, including no treatment, could affect his or her life or quality of life, and (iii) whether the person’s choice is not substantially based on a delusional belief. The Court found that “these indicators provide a useful framework for identifying what ‘ability to appreciate’ means in concrete terms.”

The Court also underscored that “the right to refuse unwanted medical treatment is fundamental to a person’s dignity and autonomy”: Starson, at para. 75. The CCB’s mandate is to adjudicate on capacity only; its conception of a patient’s best interests is irrelevant: Starson, at para. 76. It is an error to equate the presence of a mental disorder with incapacity: Starson, at para. 77.

With respect to the second element of the test for incapacity, the Court identified two important points, at para. 79:

First, a patient need not agree with the diagnosis of the attending physician in order to be able to apply the relevant information to his own circumstances. Psychiatry is not an exact science, and “capable but dissident interpretations of information” are to be expected: see Weisstub Report, supra, at p. 229. While a patient need not agree with a particular diagnosis, if it is demonstrated that he has a mental “condition”, the patient must be able to recognize the possibility that he is affected by that condition.

The Court went on to quote from Professor Weisstub with approval, at para. 79:

Condition refers to the broader manifestations of the illness rather than the existence of a discrete diagnosable pathology. The word condition allows the requirement for understanding to focus on the objectively discernible manifestations of the illness rather than the interpretation that is made of these manifestations.

The Court went on to explain that a patient need not describe his mental condition as an illness, or describe it negatively. A patient need not agree with the physician’s opinion regarding the cause of the condition. “Nonetheless, if the patient’s condition results in him being unable to recognize that he is affected by its manifestations, he will be unable to apply the relevant information to his circumstances, and unable to appreciate the consequences of his decision”: Starson, at para. 79.

The Court also highlighted that the HCCA requires a patient to have the ability to appreciate the consequences of a decision; not actual appreciation of the consequences. The Court directed that, in practice, the determination of capacity should begin with an inquiry into the patient’s actual appreciation of the parameters of the decision being made, including the nature and purpose of the proposed treatment; the foreseeable benefits and risks of treatment; the alternative courses of action available and the expected consequences of not having the treatment. It held that a patient who shows an appreciation of these parameters has the ability to appreciate the decision he makes: Starson, at para. 80.

The Court went on to note that a patient’s failure to demonstrate actual appreciation does not inexorably lead to a finding of incapacity. A lack of appreciation may derive from causes that do not undermine the patient’s ability to appreciate the consequences, including the attending physician’s failure to adequately inform the patient of the consequences of the decision. “Accordingly, it is imperative that the Board inquire into the reasons for the patient’s failure to appreciate consequences. A finding of incapacity is justified only if those reasons demonstrate that the patient’s mental disorder prevents him from having the ability to appreciate the foreseeable consequences of the decision”: Starson, at para. 81.

Did the CCB err in finding the respondent satisfied her onus when there was no direct evidence about L.H.’s ability to appreciate the reasonably foreseeable consequences of a decision or lack of decision?

Amicus argues that the CCB made an extricable error of law in failing to follow the guidance from Starson, para. 80, that holds that the determination of capacity should begin with an inquiry into the patient’s actual appreciation of the parameters of the treatment decision being made. In this case, no such inquiry was undertaken. Rather, Dr. Viljoen and the CCB, and also Dr. Van Impe, ended the inquiry into capacity having concluded, consistent with para. 79 of Starson, that L.H.’s condition results in her being unable to recognize that she is affected by its manifestations, such that she is unable to apply the relevant information to her circumstances, and unable to appreciate the consequences of her decision.

Considering this issue requires an analysis of the Court’s direction in Starson, and particularly with respect to paragraphs 79-81.

The Court in Starson, at para. 80, strongly suggests that the determination of capacity must begin with an assessment of the patient’s actual appreciation of the reasonably foreseeable consequences of a decision or lack thereof.

A patient with actual appreciation of those consequences will have met a higher standard than that which is required for capacity: the ability to appreciate the reasonably foreseeable consequences of a decision or lack thereof.

The Supreme Court stops short of requiring the inquiry into the patient’s actual appreciation. It uses “should,” not “must,” and places its guidance in the context of real-world practice. The Court ends para. 80 of Starson by indicating that if the patient shows an appreciation of the parameters of the decision being made (that is, actual appreciation), the patient has the ability to appreciate the decision he makes (that is, ability to appreciate). When one recognizes the higher level of appreciation demonstrated by actual appreciation, one can understand this conclusion as a statement that a patient with actual appreciation will have met (indeed, exceeded) the ability to appreciate standard required by the test for capacity.

Paragraph 81 of Starson instructs that a lack of actual appreciation may be due to causes that do not undermine a patient’s ability to appreciate consequences, such as a lack of appropriate information having been provided. Thus, where a patient does not demonstrate actual appreciation of the reasonably foreseeable consequences of a decision or lack thereof, one cannot conclude that they do not have the ability to appreciate those consequences without further inquiry into why they do not demonstrate actual appreciation.

I note that although the Supreme Court does not mandate an assessment of the patient’s actual appreciation, the Court of Appeal in Anten v. Bhalerao, 2013 ONCA 499, at para. 23, after quoting para. 80 of Starson, held that “this inquiry [into the ability to appreciate the consequences of the decision] must start with some evidence as to the foreseeable benefits and risks of treatment and the expected consequences of not having treatment.” See also Salem v. Dr. Hastings, 2015 ONSC 5071, at para. 39.

Dr. Viljoen relies on the decisions of the Court of Appeal in Gajewski v. Wilkie, 2014 ONCA 897, and of this court in P.R. v. Legault, 2015 ONSC 7716 to argue that the inquiry into a patient’s actual appreciation is not always required.

In Gajewski, the appellant had been found not criminally responsible on account of mental disorder on charges of assault and attempted kidnapping. At first, the appellant acknowledged having a fixed false belief at the time of the index offences, and agreed with the diagnosis of delusional disorder. After receiving information about the nature of his disorder and medications he should consider taking, he selected a particular antipsychotic medication. However, the medication could not be given to him because of abnormally high levels of liver enzymes in his blood, which had to be addressed first. By the time the appellant’s liver enzymes had normalized, he expressed a different view of his mental condition, denying that he suffered from a delusional order, and expressing his belief that he had been persecuted by the victim of the index offences. He denied any benefit in taking the medication. As a result, the attending physician found him incapable of consenting to treatment.

At the CCB hearing, the appellant testified that he believed he had delusions, and he also believed they were true. He could not explain the discrepancy in his evidence. The physician’s finding of incapacity was confirmed by the CCB, and subsequently on appeal to the Superior Court. The question then came before the Court of Appeal.

The appellant submitted that he had weighed the pros and cons of the proposed treatment and disagreed that it was in his best interest. He was concerned about his physical health and the potential adverse effects of the proposed medication.

In rejecting his argument on the second branch of the capacity test, the Court of Appeal found that the evidence supported the CCB’s finding that the appellant was unable to see that he was suffering from the manifestations of a mental disorder at the time of the hearing. The moments where he purported to accept that he had delusions were contradicted by his other testimony and by the clinical observations made by the physician. “It was open to the board to conclude that the appellant did not truly believe that he suffered from delusions. It follows from the cited passages from Starson and Giecewicz that the appellant was not able to apply the relevant information to his circumstances and thus was not able to appreciate the reasonably foreseeable consequences of taking or not taking the proposed medication”: Gajewski, at para. 49.

In P.R., at para. 18, this court relied on Gajewski:

as authority for the proposition that where… there is clear evidence before the Board that the appellant’s inability to recognise that he suffers from a major mental disorder renders him unable to apply the relevant information to his circumstances and to appreciate the consequences of his decision, an enquiry into the appellant’s appreciation of the parameters of the decision being made – that is the nature and purpose of the proposed treatment, the foreseeable benefits and risks of the treatment, the alternative courses of action available, and the expected consequences of not having the treatment – is not mandatory. A consequent failure by a Board to consider the patient’s appreciation of the risks and benefits of the proposed treatment will accordingly not necessarily lead to the Board’s decision being set aside.

In P.R., the court distinguished the decisions in Salem and Anten on the basis that those cases did not consider circumstances where there is clear evidence that the patient does not recognize that he or she suffers from a major mental disorder, and as such, is unable to apply the relevant information to their situation.

In Landry v. Strike, 2020 ONSC 6832, at para. 9, this court found that the CCB did not need to embark on the analysis into the appellant’s appreciation of the parameters of the decision being made because the appellant’s condition rendered him unable to recognize that he was affected by its manifestations, and he was thus unable to appreciate the consequences of his decision, as set out in para. 79 of Starson. The court concluded that the CCB applied the correct approach.

In my view, the law I have reviewed above is not inconsistent. Rather, it explains that the correct approach to a determination of a patient’s ability to appreciate the reasonably foreseeable consequences of a decision or lack thereof is to first inquire into the patient’s actual appreciation of the parameters of the decision before them, as described in para. 80 of Starson. If a patient does not demonstrate an actual appreciation of the parameters of the decision, it becomes necessary to inquire into why they do not, as described in Starson in para. 81. If the reasons demonstrate that it is the patient’s mental disorder that prevents them from having the ability to appreciate the foreseeable consequences of the decision, a finding of incapacity is justified.

However, consistent with para. 79 of Starson, para. 49 of Gajewski, and P.R. and Landry, there are occasions when the inquiry into a patient’s actual ability to appreciate the parameters of the decision will not be required. Specifically, this is the case where the evidence is clear that a patient’s condition results in him being unable to recognize the possibility that he is affected by that condition, or its manifestations, such that he will be unable to apply the relevant information to his circumstances.

In this case, there was ample evidence before the CCB to allow it to conclude that L.H. was unable to recognize the possibility that she is affected by a mental condition or its manifestations. Some of that evidence came from her very own testimony. In these circumstances, the CCB was not required to inquire into L.H.’s actual appreciation of the parameters of the decision to be made, and it did not err in law by not doing so.

Did the CCB err in finding the respondent satisfied her onus when there was no evidence that any information had been given to L.H. about the benefits of the treatment or the foreseeable consequences of a decision regarding it?

Amicus argues that jurisprudence requires that the physician provide evidence demonstrating that they discussed the expected risks and benefits of the proposed treatment with the patient prior to finding them incapable: see for example, Salem, at paras. 36, 39, Anten, at paras. 22-23.

This issue overlaps in significant measure with the issue I address above. If my conclusion had been that the CCB and Dr. Viljoen were required to inquire into L.H.’s actual appreciation of the parameters of the decision prior to concluding that she is incapable as to treatment, the question of the information that had been given to L.H. by Dr. Viljoen would be relevant. I agree with amicus that the documentary record is sparse on, for example, the nature of the information L.H. was given with respect to the benefits of the proposed treatment.

However, because the evidence clearly demonstrates that L.H. is unable to allow the possibility that she may be affected by a mental condition or its manifestations, the inquiry into her actual appreciation of the parameters of the decision is not required, and whether the evidence is robust on this point is not relevant to the finding of L.H.’s incapacity.

Did the CCB err in finding the respondent satisfied her onus, because there was no corroboration of the doctor’s evidence of incapacity?

Amicus also suggests that L.H. may argue that the CCB erred in confirming the finding of incapacity because Dr. Viljoen’s evidence concerning incapacity was not corroborated by other material evidence.

The parties agree that s. 14 of the Evidence Act applied in this case and requires corroboration of Dr. Viljoen’s evidence “by some other material evidence.”

Amicus notes that Dr. Bawks’ notes were not included in the document package to the CCB. I agree that Dr. Bawks’ finding of incapacity, without more, is not sufficient to be corroborating evidence.

However, I find that Dr. Viljoen’s evidence was corroborated by other material evidence, and specifically: (i) the notes of Dr. Van Impe which document L.H.’s lack of insight into her delusions and the impact they hold on her behaviour, and her inability to appreciate that antipsychotic medication could be of any potential benefit because of her insistence that she does not have a mental disorder that could respond to antipsychotic medication; and (ii) the testimony of L.H. herself, in which she denied the possibility that she is affected by a mental disorder or its manifestations. I note that L.H. continued to strongly deny the possibility that she has a mental condition in her submissions before me on the appeal.

Conclusion

In conclusion, I grant the appellant’s request to anonymize her identity in this appeal.

I dismiss the appellant’s appeal.

There shall be no order as to costs.

J.T. Akbarali

Date: February 20, 2025