England and Wales High Court (Administrative Court) Decisions

IN THE HIGH COURT OF JUSTICE
MANCHESTER CIVIL JUSTICE CENTRE

		Manchester Civil Justice Centre 1 Bridge Street West Manchester M3 3FX
		26th January 2012

Mr Justice Supperstone:

1. Dr Althaf is a registered medical practitioner. He seeks to challenge the decision of the General Medical Council's Interim Orders Panel dated 12 October 2011 to impose conditions on his registration.
2. The material parts of the Medical Act 1983 provide:

"1(1A) The main objective of the General Council in exercising their functions is to protect, promote and maintain the health and safety of the public.

41A(1) Where an Interim Orders Panel or a Fitness to Practise Panel are satisfied that it is necessary for the protection of members of the public or is otherwise in the public interest, or is in the interests of a fully registered person, for the registration of that person to be suspended or to be made subject to conditions, the Panel may make an order --

a. (a) that his registration in the register shall be suspended (that is to say, shall not have effect) during such period not exceeding eighteen months as may be specified in the order (an 'interim suspension order'); or

b. (b) that his registration shall be conditional on his compliance, during such period not exceeding eighteen months as may be specified in the order, with such requirements so specified as the Panel think fit to impose (an 'order for interim conditional registration').

(10) Where an order has effect under any provision of this section, the relevant court may -

a. (a) in the case of an interim suspension order, terminate the suspension

b. (b) in the case of an order for interim conditional registration, revoke or vary any condition imposed by the order;

c. (c) in either case, substitute for the period specified in the order (or in the order extending it) some other period which could have been specified in the order when it was made (or in the order extending it),"

3. On 10 November 2011 Dr Althaf issued an Appellant's Notice appealing against the decision of the Interim Orders Panel ("the IOP"). At paragraph 1.2 of his grounds of appeal he said that the appeal was brought under Section 41A(10) of the Medical Act 1983 as amended.
4. Mr Hare, for the GMC, submits that there is no right of appeal against the Panel's decision; the Act draws a distinction between decisions of the Fitness to Practise Panel which are appealable under Section 40 of the Act and decisions of the IOP, which are not. A doctor wishing to challenge the IOP's decision should issue a statutory application under CPR Part 8 (see R (Madan) v GMC [2001] EWHC 322 (Admin)). Mr Hare submits that there is no excuse for Dr Althaf's failure to follow the correct procedure, as he was represented by solicitors before the Panel. This is not, Mr Hare submits, a mere formality: the court's approach to a challenge to the Panel's decision is not the same as in appellate proceedings. For this reason Mr Hare invites the court to reject Dr Althaf's appeal.
5. Dr Althaf, who appears in person, says that he has not been represented since the hearing before the Panel. He is a litigant in person and should not be penalised for adopting an incorrect procedure.
6. I propose in the circumstances to treat the Appellant's Notice as if it were an application under CPR Part 8 and to apply the approach to a challenge to the Panel's decision that the court adopts on a statutory application under CPR Part 8.
7. The court's approach in challenges to order of the Panel is set out in the judgment of Nicol J in Martin Sandler v GMC [2010] EWHC 1029 (Admin) at paragraphs [12] and [13]:

"12. Both parties agreed that the role of the Court was not confined to exercising a judicial review type jurisdiction. In other words, the power to terminate Dr Sandler's suspension (or to substitute a different period) is not dependent on showing some error of law on the part of the IOP. […] My consideration of the application must surely start from the position that the IOP has thought that interim suspension is the right course.


13. … both parties acknowledged that the opinion of the Panel was entitled to respect. As Davis J said in the Shiekh case [R (Shiek) v General Dental Council [2007] EWHC 2972 (Admin) at [10]]: 'in the ordinary way the court will show respect for the decision of a Panel in this context, given that the Panel is an expert body which is well acquainted with the requirements that a particular profession needs to uphold and with issues of public perception and public confidence'."

The court does not have original jurisdiction; it is not an appeal before this court; but the role of the court is not confined to exercising a judicial review type jurisdiction.

8. Turning to the substance of Dr Althaf's challenge, the relevant background is that he came to the attention of the GMC as a result of a letter dated 19 November 2010 from Dr Obiako, a lead clinician in emergency medicine at the Prince Charles Hospital in Merthyr Tydfil who was responsible for the clinical management of the department where Dr Althaf worked from May 2010 to 12 November 2010. Dr Obiako reported "significant clinical concerns" about Dr Althaf and gave four examples of patients who had received inappropriate care from Dr Althaf, including one who had died.
9. The GMC's case examiner deferred making a decision on whether to refer Dr Althaf's case to the Panel pending receipt of further information. Pursuant to its statutory duties under the Act the GMC contacted Dr Althaf's past employers and received a number of responses, some of which reported no concerns about Dr Althaf. However, the GMC did receive letters expressing concern from Frimley Park Hospital, an NHS Foundation Trust.
10. The GMC also received a copy of the full investigation report from the health board responsible for the Prince Charles Hospital in relation to the incidents which had lead to Dr Obiako's referral to the GMC. In a covering letter dated 20 July 2011 the health board wrote as follows:

"The conclusion of the investigation was that it was clear that those patients should not have been discharged home at the time they were. They should have been admitted to the ward for further observation or further treatment. It was also identified that Dr Althaf did not follow the pathways for those patients who presented complaining of abdominal pain, or croup, or on those patients who are insulin-dependent diabetics. In addition documentation and communication were poor. The investigation process also identified inconsistencies in the way patients were managed."

11. On 22 September 2011 the case examiner decided to refer Dr Althaf to the Panel. By letter dated 26 September Dr Althaf was invited to appear before the Panel. The letter explained the procedure before the Panel and that the Panel could suspend his registration or impose conditions upon it.
12. Dr Althaf appeared before the Panel on 12 October 2011; Mr Choudhary of Medic Law appeared on his behalf.
13. The hearing before the Panel took the usual form. The Panel considered the documents presented by the GMC and Dr Althaf. The Panel is not a fact-finding tribunal and does not, as a general rule, hear from witnesses. The Panel's decisions are intended to protect the public pending the full investigation of a doctor's fitness to practise. The transcript of the hearing, which is at pages 155-201 of the bundle before this court, shows that Mr Phillips QC for the GMC presented the GMC's case and then Mr Choudhary made his submissions on behalf of Dr Althaf. No witnesses gave evidence.
14. Announcing the determination of the Panel the chairman said that the Panel had carefully considered all the information before it, including the submissions made by Mr Phillips on behalf of the GMC and those made by Mr Choudhary on Dr Althaf's behalf and the documentation provided. The Panel determined that it is necessary for the protection of members of the public and the public interest to make an order imposing conditions on Dr Althaf's registration for a period of 18 months. Nine conditions were imposed; they are recorded in the GMC's letter of 13 October 2011 notifying Dr Althaf in writing of the decision given by the Panel the previous day.
15. The Panel concluded:

"The Panel is concerned that in light of your poor record keeping, poor communication and clinical management, that the index cases are potentially all serious cases which highlights the need for an interim order. The Panel has also noted that the Trust investigation also concluded that your actions strayed from its protocol. The Panel is further concerned that you have not received any formal appraisal and that there is no evidence of your continued professional development.

The Panel is satisfied that there may be an impairment of your fitness to practise which poses a real risk to members of the public and which may adversely affect the public interest and your own interest and, after balancing your interests and the interests of the public, an interim order is necessary to guard against such a risk.

The Panel has taken account of the principle of proportionality and has balanced the need to protect members of the public, the public interest and your own interests against the consequences for you of the imposition of conditions on your registration. Whilst it notes that the above conditions restrict your ability to practise medicine, the Panel considers that the conditions are necessary to protect members of the public and the public interest whilst these matters are resolved. It is therefore satisfied that the imposition of the above conditions on your registration is a proportionate response to the risks posed by your remaining in unrestricted practice."

16. In the introduction to his grounds of appeal Dr Althaf said: "I am lodging this appeal in person to comply with the time requirements and would like opportunity to provide better grounds after seeking legal advice or representation." The grounds of appeal that he set out in paragraph 3 of that document were that the Panel made observations that are not supported by the evidence; did not fully address the case presented by the appellant; misunderstood some of the evidence; misdirected itself in appearing to seek specific evidence from the appellant which were not essential for addressing concerns raised; failed to observe the requirements of a fair hearing in neglecting to invite submissions from the parties, and in particular, from the appellant as to the practical effect of the proposed conditions before announcing its decision. The grounds state that the opportunity to make submissions at that juncture was necessary in the interests of justice and should have been afforded to the parties applying rule 27(5) of the General Medical Council (Fitness to Practise) Rules Order of Council 2004. Notwithstanding its conclusion that the protection of the public and the public interest was adequately safeguarded by the imposition of conditional registration, the Panel erred in imposing conditions that had the practical effect of debarring the appellant from engaging in medical practise and/or progressing in his carreer.
17. On 24 January 2012, two days ago, Dr Althaf filed a 108-page skeleton argument for today's hearing. Much of the skeleton argument (pages 34-108) sets out extracts from decided cases.
18. Dr Althaf submits that the Panel made numerous material errors of fact during the hearing and in their determination. In support of this submission at pages 6-18 of his skeleton argument he sets out his case in relation to the four patients. However, the Panel correctly stated in its determination that it was not its function to make findings of fact, nor decide on the veracity of the allegations. Mr Choudhary has set out at length in his submissions to the Panel Dr Althaf's response to the allegatinos in respect of the four patients. Those submissions Dr Althaf repeated to me orally, identifying in relation to each patient why he said the criticism of him was unfounded. However, the Panel noted the following in relation to the four cases:

"Patient WR, a 95-year-old lady, with an existing chest injury, who complained of chest tenderness and a swollen knee following a second fall yet was discharged at 01.17hrs. Patient AR, an insulin-dependent diabetic who self-referred to Accident & Emergency because of diarrhoea and vomiting was discharged at 22.26 with advice to take fluids and omit insulin with no reference to potential ketoacidosis. Patient PR, with abdominal pain and vomiting, was given morphine which alleviated his symptoms. He was discharged despite a persistent tachycardia without a diagnosis. Patient KF was correctly treated with dexamethasone for croup but then discharged, his parents having been given unlabelled medication with no instructions."

Dr Althaf has made clear that there are matters in relation to each case that he would wish to challenge at a Fitness to Practise hearing when the merits of the allegations are fully considered, if there is indeed a Fitness to Practise hearing. However, I can discern no material error of fact made by the Panel in relation to these cases.

19. Dr Althaf complains that the investigation that was conducted into the four cases was not a full investigation and that he has requested documentation, which he needs to defend himself, which has not been provided. He also notes that at the conclusion of the investigation report it is stated that "as the incidents occurred in the past and there was a time delay in being made aware of these, it was difficult for staff to recall the exact events". These factors combined, he submits, will make it even more difficult for him to present his case at any Fitness to Practise hearing. I appreciate his concerns. However, despite the delay and the difficulty referred to, the report concluded that "it is clear that these patients should not have been discharged home at the time that they did." This was a view which in my judgment, after consideration of the written evidence and hearing submissions from the parties, the Panel was entitled to accept for the purposes of their determination.
20. In relation to the criticisms made of him concerning the period he worked at the Frimley Park Hospital between December 2010 and February 2011, the Panel, having considered a document dated 28 February 2011 of notes of a discussion between a consultant, the emergency medicine and clinical director at Frimley Park Hospital and Dr Althaf and a statement from Ms Walsh, accident and emergency sister, dated 17 May 2011, noted in its determination that Dr Althaf's communication was poor between nurses and other doctors about patient care, and there were concerns about him continually falling asleep and failing to document much of the care given to patients in the casualty ward. These concerns led to the consultant body at the hospital agreeing that they should not employ Dr Althaf as a middle grade on night shifts, despite the fact that his patient care is satisfactory and he copes well during day shifts. Again I can discern no material error of fact made by the Panel in relation to these matters.
21. At the hearing before the Panel Dr Althaf had the opportunity to make submissions with regard to the various allegations that were made against him arising from his employment at the Prince Charles Hospital and at Frimley Park Hospital. It is clear from the transcript of the hearing that Mr Choudhary addressed all these matters on behalf of Dr Althaf. I am not satisfied that the Panel made any material errors of fact in their determination.
22. Dr Althaf submits that his Article 6 ECHR rights have been infringed, as I understand it, in two respects. First, the Panel was wrong to find that a case had been made out; second, the investigation carried out by the hospital was inadequate, and the hospitals failed to follow proper disciplinary procedures when carrying out their investigations. Further, he complains that he had no access to witnesses and documents he asked for were not disclosed.
23. Mr Hare submits that Article 6 is not engaged in the present case. He accepts, as is clear from the authorities, that suspension is a determination for the purposes of Article 6. However, if, as in the present case, the conditions that were imposed permit Dr Althaf to practise his profession then Article 6 is not engaged. If he is wrong about that and Article 6 does apply then Dr Althaf is entitled to a hearing within a reasonable time before an independent and impartial tribunal. This court is such a tribunal and he has been able to appeal the decision of the Panel on this statutory application where the jurisdiction is not confined to a judicial review type jurisdiction. In my view, for the reasons submitted by Mr Hare, Article 6 is not engaged; if it is then there has been compliance with Article 6. Further, in my view the hearing before the Panel did not infringe Dr Althaf's Article 6 rights. The transcript of the hearing shows that the Panel carefully considered the allegations made against Dr Althaf, what Dr Althaf had to say about them, and made a determination that a prima facie case was made out as they were entitled to on the evidence presented to them.
24. Similarly, I reject Dr Althaf's submission that his Article 8 ECHR rights have been infringed by the Panel's determination. His registration has not been suspended and he is still able to practise his profession. He complains that his reputation has been adversely affected by the decision of the Panel. The conditions that have been imposed have been imposed on an interim basis. I do not accept that there has been interference with his civil rights. If I am wrong about that, as Mr Hare submits, Article 8 is a qualified right and I am satisfied that the Panel had properly engaged in a balancing exercise and any interference with his right is justified.
25. Dr Althaf raised the question of the standard by which he should be judged. In my view this issue does not arise; the application of Section 41A(1) does not depend on the doctor having fallen below a particular standard. The Panel reached its decision on the basis of the evidence presented before it, that there may be a risk to patients, having taken into account relevant matters and conducted the balancing exercise that had to be done. Dr Althaf submits that the Panel was wrong to express a concern that he had not received any formal appraisal and that there was no evidence of his continued professional development. I reject that submission. The Panel properly considered these matters in the context of considering the testimonials put forward by Dr Althaf. The Panel state that they took account of the positive testimonials from Dr Althaf's professional colleagues and there is no reason to doubt that they did so. Dr Althaf submits that the conditions that were imposed, in particular condition 5a and condition 8 (but also conditions 6 and 7), mean that he is effectively debarred from medical practise. I do not accept this submission. Dr Althaf seeks to put in evidence a letter dated 10 November 2011 from Dr Ironside at the College of Emergency Medicine who answers specific queries raised by Dr Althaf on points 5a and 8 of the conditions.
26. Mr Hare objects to the admission of this evidence on two grounds. First, this court is reviewing the decision of the Panel and therefore the court is principally concerned with the material before the Panel (see Sandler at paragraph 2); second, section 41A(2)(b) strongly suggests that new evidence should be considered at a review of the decision by the Panel; that review can be brought forward for example in the circumstances where there is new evidence. In my view that is the appropriate forum for the consideration of this evidence from Dr Ironside and also the further email evidence referred to by Dr Althaf concerning the post he applied for in intensive care with Dr Steele's Trust.
27. I am not satisfied on the evidence before me that the conditions imposed amount to a suspension as Dr Althaf submits. The conditions are each drawn from the GMC bank of standard conditions. Having reached the decision which I have with regard to the conditions, it is not necessary for me to deal with the evidence of Dr Ironside and Dr Steele in any detail; it suffices to say that Dr Ironside puts forward two alternative interpretations of condition 5(a), the first of which Mr Hare submits is correct and which would enable Dr Althaf to work. Dr Ironside in any event advises Dr Althaf to seek clarification from the interim orders Panel on the correct interpretation of the conditions.
28. At the review hearing before the Panel Dr Althaf will have an opportunity to apply for a variation of his conditions if he is able to establish that they are causing particular hardship. He will be able to put forward the evidence on which he relies in a proper form and the GMC will have an opportunity to respond and adduce evidence on which they wish to rely. The Panel, as a specialist Panel, will then make a decision as to whether the conditions are workable or not.
29. There is no requirement for the Panel to invite submissions on the order it proposes to make. The power to suspend his registration or to impose conditions was clearly set out in the letter inviting Dr Althaf to the hearing. In Russell v GMC [2008] EWHC 2546 (Admin) at paragraph 32 Dyson LJ, as he then was, said:

"There is no authority for the proposition that the Panel or a body performing similar functions has to draw to the parties' attention the fact that it is minded to impose any particular form of sanction."

30. Finally, in his skeleton argument Dr Althaf complains about the Panel's decision to reject his application for a postponement of the hearing which he made on receipt of the notice of hearing. No application for an adjournment was made at the hearing. I reject this ground of challenge. In my judgment Dr Althaf has failed to make good any of his grounds of challenge to the decision of the Panel of 12 October 2011 imposing conditions on his registration. Accordingly, this application is dismissed.

MR HARE: My Lord, I am obliged. There are just two matters arising from the judgment, if I may?

MR JUSTICE SUPPERSTONE: Yes of course.

MR HARE: the first is …

MR JUSTICE SUPPERSTONE: Do take a seat Dr Althaf, I will hear from you in a moment.

MR HARE: The first is just a slip of the tongue, but your Lordship referred in his description of the hearing to the hearing on 12 October 2001, I thought it was 2011.

MR JUSTICE SUPPERSTONE: Thank you very much, please correct that.

MR HARE: Yes. I also wondered if in the very final line "appeal dismissed" that it would be more appropriate to say the "application is dismissed".

MR JUSTICE SUPPERSTONE: I think that is absolutely right because I am treating it as an application.

MR HARE: Yes.

MR JUSTICE SUPPERSTONE: Thank you very much, so the application is…

MR HARE: There are the only two points on that.

MR JUSTICE SUPPERSTONE: … dismissed.

MR HARE: Yes. My Lord, I do make application on behalf of the General Medical Council for its costs.

MR JUSTICE SUPPERSTONE: Yes.

MR HARE: of defending the application. Copies of our statements of costs were sent to the doctor and the court but may not be before your Lordship. I have spare copies …

MR JUSTICE SUPPERSTONE: I have seen it … I appreciate your making this application on instructions and in the financial circumstances of Dr Althaf we have heard about; he has been out of work for some time and we have heard about his personal circumstances, but this is an application that you are instructed to make.

MR HARE: It is, and we would say that matters to do with his means are questions of enforcement rather than the principle of whether or not the General Medical Council is entitled to its costs.

MR JUSTICE SUPPERSTONE: Yes.

MR HARE: The hearing stated today that presumption is, of course, we have succeeded on all the points therefore costs ordinarily would follow, and we would say because it has only taken a day they ought to be summarily assessed. My Lord, I won't take long on it, but I regret to say there are actually two statements of costs because there is a supplementary statement

MR JUSTICE SUPPERSTONE: Ah … I don't … yes, I have seen one headed "supplementary", I am not sure I have seen the original one.

MR HARE: … the first one … I can hand to your Lord.

MR JUSTICE SUPPERSTONE: Do you have these documents, Dr Althaf?

DR ALTHAF: I have them.

MR JUSTICE SUPPERSTONE: Thank you very much.

MR HARE: Could I take the first one, not the supplementary one first?

MR JUSTICE SUPPERSTONE: Yes.

MR HARE: I … of course you will hear from Dr Althaf if you are minded to award anything at all. I just wanted to make a couple of points about the sums involved. The first is, in relation to work on documents, the GMC, although the respondent to the application, has produced most of the documents as your Lordship has seen in the authorities bundle and the bundle that was below and in relation to attendance at the hearing, it was a paralegal who attended me today and the claim has only been put in there for one hour of attendance. I don't know of any extra claim, I am just saying that if anything this is under…

MR JUSTICE SUPPERSTONE: Yes …

MR HARE: The supplementary statement of costs is …

MR JUSTICE SUPPERSTONE: So that is in the sum of £588 752.

MR HARE: Yes that is correct, my Lord, with VAT only on my fees. There is then a supplementary statement which your Lordship indicated he had seen; that was caused by the arrival two days ago of the 108 page skeleton and several hundred pages of further documents. However, I make no further comment on that, but I just wanted to offer that explanation. I have totted up the relevant figures, if your Lordship is interested.

MR JUSTICE SUPPERSTONE: Yes, you have probably got there quicker than me…

MR HARE: I did it yesterday otherwise it would have taken a lot longer … but the grand…

MR JUSTICE SUPPERSTONE: Yes, thank you very much. Dr Althaf, as you appreciate, the application for costs has been made on the basis that the GMC have won, you have lost on every single point; this hearing has taken a day. Can I take this in stages for you? First of all I would normally ask the question whether in principle you agree that the GMC are entitled to their costs. In principle they are, but I will hear from you on that. Let me just put you the two points. The next stage, if that is right in principle, is the amount of their costs. Now I don't know whether you have had an opportunity to go through this, I don't know whether it is meaningful to you, whether you understand how the figures have been calculated, albeit they are set out in the standard form, whether you have anything to say about the amount of costs. I well appreciate what you wish to say and that is why I put to Mr Hare the point about your financial circumstances and personal circumstances, but what Mr Hare says, rightly, is well that is a matter for enforcement as to whether the costs order if I make it is enforced against you. It doesn't go to the question of whether a costs order should be made in the first place. However you like to deal with it, you say what you would like to say.

DR ALTHAF: I would appreciate your patience for one minute. I have a question. I accept that the judgment has been made, I am not seeking to overturn. I am seeking …

MR JUSTICE SUPPERSTONE: Well you are perfectly (inaudible) perfectly entitled, Dr Althaf,H when you get a copy of it because it should be transcribed, however you may have made some notes, to take legal advice on it, and if you are told that I have got it wrong then you will be advised as to what to do.

DR ALTHAF: The two questions I was going to ask were about the case that was quoted, Nicol, sorry yes … Nicol where (inaudible) determined the…

MR JUSTICE SUPPERSTONE: Nicol J.

DR ALTHAF: Mr Justice Nicol.

MR JUSTICE SUPPERSTONE: Case …

DR ALTHAF: Case of Sandler. And the ruling on that I …

MR JUSTICE SUPPERSTONE: This …

DR ALTHAF: I won't go into it, your Honour.

MR JUSTICE SUPPERSTONE: No, this is not an occasion to even enter into debate on that.

DR ALTHAF: I don't intend to…

MR JUSTICE SUPPERSTONE: I have made my ruling, that is my decision, I only want to hear from you on costs.

DR ALTHAF: I don't intend to. All I was going to say was that it was in my authorities and I am unsure that I got it wrong. I thought it meant other than it appears it does, and I thought I had other authorities to support my point of view.

MR JUSTICE SUPPERSTONE: Yes.

DR ALTHAF: The second is again the case of Russell that was just mentioned, and I had in my authorities highlighted that the next paragraph of the ruling quoted points out that the reasons were given, the judgment concerned the fact that the Panel did not need to advise on a specific sanction but it did invite submissions for mitigation before sanction, it did not reject that option altogether. It is in the next paragraph and I had submitted it in my authorities. I am obviously …

MR JUSTICE SUPPERSTONE: Dr Althaf, this is an opportunity for you to say something about costs. Let me try and help you. Have you looked through the statements of costs, have you taken advice as to whether they look reasonable? Do you want to reserve your position?

DR ALTHAF: I cannot take advice your Honour, because obviously my financial circumstances are what they are. This was the option that was open to me for review or challenge or appeal against this determination and I appreciate that as a non-specialist I have not been able to challenge the medical aspect of it and I have obviously lost. In terms of costs I cannot make any comment beyond what I have which is that I am unable to work at this time, I do not know when I will be able to work because while the judgment suggests that the review Panel is the right place for this, it does not... what I have been given to understand elsewhere doesn't appear to support that, and I am given a date potentially of 24 March. I have not had communication of that date or indeed any notice of this further and … Until I can start working again I pay people who have already lent me monies to live on. Considering that I am not in receipt of any state aid I can only submit that it is unfeasible amount of what should have been a statutory right to at least appeal or challenge a determination which to me was not well founded.

MR JUSTICE SUPPERSTONE: Yes, thank you very much. In my judgment the GMC is entitled to its costs. I have looked at the statements of costs to see whether any items appear to be unreasonable, appreciating that Dr Althaf is a litigant in person. It does not appear to me that they are unreasonable and in those circumstances I award the GMC their costs in the total sum of £7,361.92. Dr Althaf, the question of enforcement will be another matter. Can I just thank you, Dr Althaf, for putting forward your submissions very clearly, and Mr Hare for your assistance, and I do recommend Dr Althaf that if you could take some legal assistance and seek some legal assistance before you proceed further I really think that would be a benefit to you because I appreciate your financial circumstances and the position that you are in, but when you receive the transcript of this judgment, as I say, you must decide what to do, but you would be better seeking legal assistance and some legal help.

DR ALTHAF: Your Honour, a very brief question, if I may …

MR JUSTICE SUPPERSTONE: Yes.

DR ALTHAF: Do I seek permission to appeal or is that something that can be considered. The main reason I seek permission is because the case that was made against me was primarily medical, was primary clinical. I have attempted to highlight the material errors that to me are material errors of fact made by the Panel. Obviously that is not something that has been found, but I … I would... I am unclear as to how I can challenge any other material errors of fact and I would seek permission for advice as to ….

MR JUSTICE SUPPERSTONE: Yes. Well Dr Althaf, I think it may assist you procedurally if I deal with your application now and I reject the application in my judgment. No grounds for appeal have been put forward that are arguable or raise any prospect of success and having made that decision you then have a period of time in which to consider whether to appeal my decision, including my refusal of permission to the Court of Appeal. So that concludes the matter before me, so if you wish to take this matter further you need to put in an application to the Court of Appeal.

DR ALTHAF: Thank you, your Honour.