England and Wales High Court (Administrative Court) Decisions

IN THE HIGH COURT OF JUSTICE
QUEEN'S BENCH DIVISION
ADMINISTRATIVE COURT

		Royal Courts of Justice Strand, London, WC2A 2LL
		29 March 2012

Mr Justice Eady :

1. Dr Ayyub appeals a direction of the General Medical Council's Fitness to Practise Panel, dated 8 March 2011, to the effect that his name should be erased from the Medical Register. The appeal is pursuant to s.40 of the Medical Act 1983. The determination on that occasion followed a finding that Dr Ayyub's fitness to practise was impaired in the light of his conduct in relation to two separate incidents.
2. The first incident concerned a young female patient ("CB"), who was examined by Dr Ayyub on 24 November 2008 at the Leeds Teaching Hospital where he was employed as a Foundation Year Two doctor. She had presented with flu-like symptoms, nosebleeds (epistaxis), leg cramps, tachycardia and general weakness. Before he saw the patient, a nurse had ordered full blood count, urea and electrolytes and clotting tests. This had been recorded on the medical notes and on the hospital's computer system. Without seeing the results of the tests, Dr Ayyub discharged the patient, having concluded that she was likely to be suffering from influenza or some viral infection. Nevertheless, he entered on the computer records a note to the effect that all investigations, including blood tests, had been completed. Once the blood tests were returned, it was clear that they were abnormal and the patient was readmitted and diagnosed with the potentially fatal Weil's syndrome or lemptospirosis (contracted from a rat which she had taken in as a pet). Fortunately, she was readmitted the day after Dr Ayyub had discharged her.
3. This led to a complaint by CB's parents, which included the allegation that Dr Ayyub had taken CB out of the emergency department in a wheelchair because she was too weak to walk. An investigation took place, conducted by Dr Jonathan Jones, a consultant in emergency medicine, who asked Dr Ayyub in an email of 16 December 2008 a number of questions:

"You will remember the young woman with epistaxis who turned out to have Weil's disease. I wonder if I could ask a few specific questions as I formulate a response to a complaint from her father.

1) Had you noticed that her HR was 125 at initial assessment. Did you reassess it? You have written 'obs stable' in the notes.

2) Her father has suggested that she was too weak to walk and needed to be wheeled out of the department. What is your opinion of this?

3) What was your general opinion of her clinical condition?

4) Did you know blood tests had been done and if so did you see the results?"

4. Dr Ayyub sent a reply the following day by email in these terms:

"Dear Dr Jones. Thank you for contacting me regarding the issue. I was sorry to hear of this incident that occurred. I was first aware of this and was notified by Dr Cormack the day afterwards due to the bloods results being phoned through. I discussed the case with Dr Cormack and said he was expecting weil's disease and he said that since I had not seen the bloods he would have probably thought it was just a flu/cold in the same situation. I was not aware that bloods had been taken from the patient and should have doublechecked this. Nothing was typed on the card and with the clinical presentation I did not think the nurses would have taken bloods in this situation as she was young and seemed like cold/flulike symptoms. I remember the patient well. She was a young lady who I say [sic] near the end of one of my shifts. When I assed her she looked unwell, however given the history I was given, my judgement was that this probably a viral infection or the 'FLU'. I was aware of her being tachycardic on admission and I did reasses her and that point her heart rate was lower than before. If I remember correctly it was around 100, which I know is still borderline. I gave her some advise and tell her to return if the symptoms did not improve with supportative measures. In terms of the patient being wheeled out of the department due to being to weak to walk, I was not aware of this aspect. I am glad she is making a full recovery and if I can be of any further help please do get in touch."

5. A meeting took place later, on 3 February 2009, to clarify what Dr Ayyub's stance was in relation to patient CB. Dr Jones and Dr Ayyub were both present together with Dr Reynard, who was the Clinical Director, Urgent Care. The minute of the meeting records as follows ('AA' being Dr Ayyub):

"AA said that he might have got her a wheelchair if they had asked. AA went on to add 'I might have clicked her off and might have got her a wheelchair if they had asked'. AA went on to add that he could not remember whether he had wheeled CB to the door.

KR asked AA to be more precise in his account of events, initially asking what AA meant by a 'quick examination'. AA responded that he felt the pulse which was 105-110/minute, had a quick listen to the chest and looked in her nostrils. He is unsure if he listened to the heart sounds or examined the abdomen, but reported that we would normally have done this. AA stated that he has 'not written anything else down so that leaves me open'.

…

JJ asked 'did you get her a wheelchair?' AA responded that he might have but he could not remember fully 'but I might have if her mum says I did. Thinking on I might have got her a wheelchair if they asked'.

JJ asked 'did you wheel her out?' AA responded 'I might have'. He went on to explain that he might have thought that CB's mother being more protective.

JJ went on to say that this was an unusual case and that he would expect someone to remember events. JJ stated that the issue relating to blood results was one of carelessness.

KR explained that this was a serious issue. The first issue related to AA not recognising that blood tests had been done. AA repeated that he was unaware of them and had not seen the page with the notes written on them. KR reconstructed the A & E notebook to show that the blood tests were recorded on the sheet directly facing that which AA had written his notes on.

KR also explained that AA appeared to have recorded on the computer that tests had been completed. KR asked whether AA accepted that he had clicked the 'investigations are complete' box. AA accepted this and stated that his password had not been shared with others so it must have been him. He offered no explanation for this action other than his view that 'sometimes they are written down and not done'.

KR explained that the second issue was one of whether AA's account in his statement regarding the complaint was truthful. KR showed AA his statement [i.e. the email response of 17 December] where he wrote 'In terms of the patient being wheeled out of the department due to being too weak to walk, I was not aware of this aspect'. KR reminded AA that he was aware of the significant issues involved in this case on the day after her initial attendance, and that his response to the complaint was made on 17/12/2009 [sic].

KR stated that he needed AA to tell him what did happen – not what may or may not have happened. AA replied that he could not recall wheeling her out of the dept. He might have handed her a wheelchair but could not recall standing her up. KR stated that if he got her the wheelchair than he must have been aware that she had difficulties walking. AA responded that he did not think that much to their asking for a wheelchair and that he was not sure if he thought anything of it at the time 'if they did ask for a wheelchair'.

AA replied that on occasion he has helped patients in this way. KR asked if this would strike him as unusual in the context of having diagnosed a 'flu' like illness. AA responded that maybe he was thinking that CB's mother was being protective and supportive of her daughter rather than it being a reflection on CBs clinical state. AA could not recall seeing CB on her feet. He felt that if she had tried to walk and fallen down that would have been different.

KR stated that he was trying to piece together what may or may not have happened. 'Did you bring her a wheelchair and then go out of the cubicle [while she got in it] and then go back in?' AA replied that he could not clearly remember one way or the other.

KR summarised that there were two significant issues:

1) The issue of the blood tests – AA failed to appreciate blood tests had been done despite two safeguards in the system – firstly that the tests having been done was written in the notes (although not in the usual space that this would be recorded) and secondly that the tests having been done was recorded on the computer system.

2) The issue of probity relating to AAs statement regarding his recollection of CB leaving in a wheelchair … "

6. A further meeting was held on 13 May 2009. On this occasion, those present were Mrs Michelle Holland, who was the Divisional Human Resources Manager for the Leeds Teaching Hospitals Trust, Dr Bryan Gill, Dr Ayyub himself and also his representative, Dr Jim Rodger. On this occasion, the minutes included the following passages concerning the wheelchair allegation:

"AA replied that he did not recall when interviewed whether he had got a wheelchair or not, he stated that the interview with Dr Jones and Dr Raynard [sic] was quite pressing.

AA went onto say that he could not recall the details but that he never stated that he definitely did or did not get a wheelchair.

BG asked whether or not AA regularly got wheelchairs for patients? AA replied that he did sometime and that it was a supportive gesture.

BG asked AA whether this had also entailed wheeling the patients out of the building. AA replied it had in the past if this had been supportive."

7. So far as this incident is concerned, the Panel's main concern was the extent to which Dr Ayyub had been honest during the investigation into the incident. By the time the appeal took place on 15 March 2012, the only outstanding substantive issue in relation to Patient CB was Dr Ayyub's challenge to the Panel's finding that he had used a wheelchair to take Patient CB out of the Emergency Department on 24 November 2008 and its finding that he subsequently made misleading and dishonest statements about this.
8. The second area of inquiry before the Panel concerned a later incident when, as it were between patients, Dr Ayyub downloaded some pornographic material while he was conducting a pre-assessment clinic on 8 April 2009. The facts are not in dispute. It seems that he downloaded a pornographic film on to a hospital computer in his consulting room and attempted to play it. The computer did not have the relevant driver (a CODEC) for the purpose of viewing certain types of file. His first attempt was thus unsuccessful but, nothing daunted, he eventually managed to download the CODEC. He was still unable to play the film because he did not have full administrator rights on the computer. Thereafter, on the same day, Mr Archer the IT Manager contacted Ms Jeffers, who was the Directorate Manager of the Head and Neck Services in the Leeds General Infirmary. She then made inquiries into the inappropriate use of a Trust computer.
9. Two days later, Dr Ayyub attended a meeting with Ms Jeffers and a registrar called Neeraj Sethi, who accompanied her "to act as a witness and provide support where required". The minute of 10 April records Dr Ayyub's version of events at that stage:

"I explained to Dr Ayyub that IT had been alerted to a specific pc which appeared to have a virus and had witnessed the user attempting to open a pornographic image then download some software to facilitate this when the original attempt failed. The user then logged into face book and IT were able to make a positive identification.

Dr Ayyub immediately admitted to logging into face book but said that he had been re-routed to the inappropriate site. In an attempt to close it down the image had opened up and started to download. Dr Ayyub denied trying to do this deliberately.

I explained the seriousness of the issue and that I was excluding him from work. I gave him a letter outlining the situation and what would be expected of him from this point on. I also gave him a copy of the Code of Conduct for Doctors where it clearly states that the misuse of the Trust IT System, including the internet is classified under the category of Gross Misconduct.

We further discussed the general use of the internet and I pointed out to him that pornography aside using face book whilst conducting a clinic was totally inappropriate and would require disciplinary action in itself. I also pointed out that by acting in this way he had opened himself up for a much more serious accusation. Dr Ayyub accepted this."

10. A somewhat different version was given by Dr Ayyub at the meeting on 13 May 2009, to which I have already referred in the context of Patient CB, where the pornography incident was also discussed. What he had to say on this occasion is also recorded in the minute:

"AA replied that he had logged in and whilst on UTube but he could not remember exactly he saw an advert for a pornographic site, so he typed the URL address into the search bar on the computer toolbar. He added that he expected the site would be blocked.

MH asked to clarify that AA had actually typed the URL address of the site into the toolbar.

AA confirmed that this was correct. He added that he was surprised when the site came up and that he was only on it for a few minutes.

BG asked what happened next.

AA stated that he had tried to open a music video and had gone into a website to download files to enable this.

BG asked if he could remember what the video was.

AA replied he could not remember. He added that he downloaded the file onto the desk top and when he clicked to open it would not open.

He stated that he then went into a different software site to download a further file to enable the music file to work.

BG asked if this allowed you to download other videos.

AA replied it did and that he had downloaded the music file from UTube, when this did not work he downloaded a file from a Codec site and then watched the music video.

BG asked AA to explain what happened next.

AA stated that he then typed in the address of the pornographic site into the same website the video came on.

MH asked to clarify the sequence of events.

1. You go into UTube

2. you see an address for a pornographic site

3. you type the URL address into the tool bar

4. you see the pornographic site

AA confirmed this was correct.

MH continued

1. You then tried to download a video from UTube

2. This failed so you downloaded a Codec file to enable the video

3. you downloaded a music video

4. you then downloaded the pornographic video

AA confirmed that this was correct."

11. At the time when Dr Ayyub took up his post at the Leeds Teaching Hospital, an enquiry was already pending before the GMC in connection with complaints about his probity. This complaint related to information he had given when applying for a previous post. It resulted in a hearing before a Fitness to Practise Panel in April 2010. On that occasion the Panel found that he had made a series of misleading and dishonest statements/omissions in connection with applications for training posts. He had consequently been suspended from the Medical Register for three months.
12. The present appeal, however, relates to a separate hearing before the Panel which commenced on 28 February 2011 and concluded on 8 March 2011. At that stage, Dr Ayyub chose not to give evidence.
13. I should set out the admissions made by Dr Ayyub at the outset of the 2011 Panel hearing. In relation to Patient CB, he made the following admissions:

i) He examined her in the Emergency Department in Leeds General Infirmary on 24 November 2008 and (a) did not take account of the fact that blood tests had been conducted, (b) did not check the blood results, (c) completed the Symphony IT system to confirm that all investigations, including blood tests, were complete, and (d) discharged Patient CB.

ii) He sent an email to Dr Jonathan Jones on 17 December 2008 in which he stated that he: (a) was not aware that blood tests had been initiated, (b) was aware that the patient was tachycardic on admission and reassessed her, (c) gave her advice and told her to return if the symptoms did not improve, and (d) was not aware that Patient CB had been wheeled out of the department.

14. In relation to the pornography allegations, these admissions were made:

i) On 8 April 2009, while he was conducting a pre-assessment clinic in the ENT Department at Leeds General Infirmary, he (a) entered a URL address for a pornographic website into the search toolbar of a computer in his consulting room, (b) downloaded pornographic material, and (c) attempted to play the pornographic film clip.

ii) On 10 April 2009 he attended a meeting with Elaine Jeffers at which he stated that (a) he was on the Facebook website, (b) he was automatically re-routed to the pornographic site, and (c) the pornographic site automatically downloaded the image.

iii) The statements referred to above were misleading and dishonest.

iv) On 13 May 2009 he attended a meeting with Dr Bryan Gill and Mrs Michelle Holland at which he stated that he had attempted to download a CODEC to enable him to play a music video.

15. No challenge is made on this appeal as to the findings in relation to the pornography. As I have already indicated, there is a challenge to the factual finding in relation to Patient CB as to the use of a wheelchair but, otherwise, the only complaint is as to the decision to impose the sanction of erasure.
16. The Panel approached the task in three stages in accordance with general practice. First, there was a determination on the facts. Secondly, there was a decision as to whether Dr Ayyub's fitness to practise was impaired. Finally, there was the determination on sanction. This process is in accordance with Rule 17 of the GMC (Fitness to Practise) Rules 2004.
17. The Panel's role at each of these three stages is recognised as being separate and distinct: see e.g. Cohen v GMC [2008] EWHC 581 (Admin) at [16]-[18].
18. The primary objective of the GMC in exercising its statutory functions is to protect, promote and maintain the health and safety of the public: see s.1(1A) of the 1983 Act. The powers of the Fitness to Practise Panel are identified in s.35D(2) of the 1983 Act:

"(2) Where the Panel find that the person's fitness to practise is impaired they may, if they think fit –

(a) except in a health case, direct that the person's name shall be erased from the register;

(b) direct that his registration in the register shall be suspended … during such period not exceeding twelve months as may be specified in the direction; or

(c) direct that his registration shall be conditional on his compliance, during such period not exceeding three years as may be specified in the direction, with such requirements so specified as the Panel think fit to impose for the protection of members of the public or in his interests."

19. The matter of "impairment" is addressed in s.35C(2):

"(2) A person's fitness to practise shall be regarded as 'impaired' for the purposes of this Act by reason only of –

(a) misconduct;

(b) deficient professional performance;

(c) a conviction or caution in the British Islands for a criminal offence … ;

(d) adverse physical or mental health; or

(e) a determination by a body in the United Kingdom responsible under any enactment for the regulation of a health or social care profession to the effect that his fitness to practise as a member of that profession is impaired … ."

20. The powers of the High Court on an appeal against a sanction imposed by a Panel are listed in s.40(7) of the 1983 Act:

"(7) On an appeal under this section from a Fitness to practise Panel, the court may –

(a) dismiss the appeal;

(b) allow the appeal and quash the direction or variation appealed against;

(c) substitute for the direction or variation appealed against any other direction or variation which could have been given or made by a Fitness to Practise Panel; or

(d) remit the case to the Registrar for him to refer it to a Fitness to Practise Panel to dispose of the case in accordance with the directions of the court, and may make such order as to costs … as it thinks fit."

21. My attention was drawn to a number of authorities in which the court's jurisdiction under s.40 of the 1983 Act has been considered: Fatnani v GMC [2007] 1 WLR 1460, at [16]-[20]; Meadow v GMC [2007] QB 462 at [30], [125]-[128] and [197]; Chyc v GMC [2008] EWHC 1025 (Admin), at [4]; and Bright v GMC [2008] EWHC 3039 (Admin), at [11]-[13] and [17]. Ms White, for the GMC, laid emphasis on the following uncontroversial principles in the light of those cases:

i) The Panel is concerned primarily with the reputation and standing of the medical profession rather than with the punishment of the doctor concerned.

ii) The judgment of the Panel is entitled to particular respect, as the body best qualified to judge what the medical profession expects of its members in matters of medical practice and also as to what measures are required to maintain the standards and reputation of the profession.

iii) It is said that a s.40 appeal is by way of rehearing, although normally the High Court would not hear the witnesses or have the same opportunity of making an assessment of the individuals concerned. Furthermore, the High Court will not interfere with the decision of a Panel unless persuaded that it was "wrong". Thus, the High Court is expected to exercise a "secondary judgment" as to the application of the principles to the facts of the particular case.

22. I turn next to the first ground of appeal, concerned with the factual findings in relation to the allegation about Patient CB and the use of a wheelchair.
23. The GMC chose not to adduce any direct evidence that a wheelchair had been used. In those circumstances, Dr Ayyub complains that the Panel would almost inevitably have drawn an inference, from the fact that the allegations had been put in the first place, that there must have been a complaint to that effect from CB's parents. It is not disputed that that would be the natural inference for the Panel to draw. There is no reason, however, to suppose that the Panel placed any particular weight on the mere fact that such an allegation had been made. The central question is whether or not the Panel was entitled to draw an inference from the evidence before it that Dr Ayyub had indeed wheeled Patient CB out of the premises.
24. His counsel, Mr Stern QC, submits that in the absence of any directly adduced evidence to that effect, there was nothing upon which to base such an inference. Ms White, for the GMC, contends on the other hand that there was ample material to support the inference. In particular, she argues that Dr Ayyub must have recalled this particular patient clearly, since he had made a blunder in discharging her from hospital on 24 November 2008, despite not having checked whether the blood tests had been carried out and, if so, with what result. The very next day, he had been informed that she had to be readmitted and that she had been diagnosed with Weil's syndrome. In any event, in his own email of 17 December 2008 he had responded to Dr Jones, "I remember the patient well". In those circumstances, she argues that it is correspondingly unlikely that he would not remember, one way or the other, the circumstances of her departure. He was giving differing and evasive answers as to whether he had used a wheelchair or might have done. Ms White suggests that this havering, and apparent lack of memory of something so memorable, provide in themselves grounds for supposing that Dr Ayyub was trying to hide something; that is to say, to pretend that he could not clearly remember how weak the patient was at the time of her discharge.
25. On the question of Patient CB's blood tests, the Panel attached significance to the patient record (known as the "CAS Card"). On the front page of this record there is a box entitled "Intervention at Assessment", in which ordinarily it would be recorded that any blood tests had been ordered. This was in fact left blank. On the other hand, once the card is opened there would confront the reader two pages side by side. On the left hand page, Dr Ayyub made his notes at 7.20 p.m. on 24 November, recording details about Patient CB. On the right hand side, there was written out in manuscript "FPC, U and E, clotting". These should have indicated to Dr Ayyub quite clearly that blood tests had been ordered. The note "U and E" signifies urea and electrolytes.
26. It is important to note in this context what the Panel took to be Dr Ayyub's weasel words in his email of 17 December, when he responded to Dr Jones, in attempting to explain why he might not have spotted that blood tests were awaited, that "nothing was typed on the card …". It was, of course, literally true that the reference to the blood tests was not typed, but it was clearly legible in manuscript. He may simply have been referring to the front page, where most of the entries were typed. It was certainly true that the box in which one would expect to find a (typed) record of blood tests had been left blank. Yet that would hardly be an excuse not to read the internal (manuscript) note to that effect.
27. Mr Stern suggests that there is an inconsistency between the Panel's adverse inference in relation to the reference to "typing" and their finding on 2 March 2011 that his statements to Dr Jones (to the effect that he was "not aware that blood tests had been initiated") had not been misleading. Ms White, on the other hand, submits that there is no inconsistency between that finding and the criticism of his "weasel words" in saying that there was nothing "typed" on the CAS Card. He may have missed the reference to blood tests through carelessness but later tried to mislead by his choice of words on 17 December.
28. Given that the GMC chose not to adduce any evidence about the wheelchair, the scope for drawing an inference about it was rather narrow. Nevertheless, I conclude that the Panel was entitled to draw it, not least from the changes in Dr Ayyub's account and from the likelihood that he would recall the young woman (as indeed he accepted). Since he was reminded of the incident the very next day, on her readmission, the Panel was entitled to take the view that it would be almost inconceivable that he could have forgotten (if it was the case) that he discharged a patient, who was too weak to stand, by wheeling her out of the department. Either he did or he did not, but he would hardly forget over the course of less than 24 hours. His claim that he "might have" done so was one the Panel was entitled to find disingenuous.
29. As I have already noted, there is no longer any challenge in relation to the pornography allegations save as to the severity of the sanction imposed.
30. Before I come to the matter of sanction I should record what the Panel actually found in relation to pornography:

"In relation to the second area of concern, your viewing pornography whilst in a clinic setting, you admitted that you did download pornographic material and that you had attempted to play a movie clip. However, you denied attempting to download a CODEC in order to play the pornographic movie clip. This was found proved by the Panel after hearing the evidence of the IT Manager. The Panel noted that you admitted making misleading and dishonest statements about this incident at a meeting on 10 April 2009. It also found that you were dishonest in your explanation given at a meeting on 13 May 2009 that you only attempted to download the driver CODEC to watch a music video and not a pornographic movie clip. The Panel considers your conduct in viewing pornographic material in a clinic room before seeing a patient to be as Mr Jenkins put it "wildly inappropriate". It further considers that it would be regarded as deplorable not only by the profession but also by the wider public.

Of further concern to the Panel is your misleading attempt to minimise your wrong doing by giving a false explanation for your actions. Your attempt to present the use of the CODEC as appropriate when it was clearly inappropriate is evidence of your attempting to put up a smokescreen and to deflect from the reality of your actions. You lied to your Trust and have maintained these lies by not admitting to this Panel the real reason for your attempting to download the CODEC driver."

31. It is quite clear that the Panel should be given particular respect in its approach towards the question of sanction, since its members are likely to be well placed to determine the appropriate measures required to maintain the standards and reputation of the medical profession: see e.g. GMC v Fatnani and Raschid [2007] EWCA Civ 46 at [17]-[20]. What the Panel actually said in this context was as follows:

"The Panel has had no evidence of any repetition of similar behaviour since April 2009 and it has noted your acknowledgment of fault and your expressions of regret. However, it has found that the recurrent theme in this case has been your dishonesty and your reluctance to tell the truth at the time of the events in question. The Panel has in mind the context of your misconduct, namely that it was committed when you were aware of investigations about your probity by the GMC. The Panel has found that your dishonest conduct has been persistent and repeated and also included several serious departures from the relevant professional standards set out in Good Medical Practice. The Panel went on to consider the fundamental question of whether your conduct is or is not fundamentally incompatible with remaining on the register.

The Panel, in discussing the appropriateness or not of suspension went on to consider the level of your dishonesty and the likelihood of its repetition. …

The Panel in its impairment determination considered that you had a significant lack of insight into your misconduct. It has now heard from you and considers that you have demonstrated some insight into your conduct, but considers it to be insufficient. It noted your response to a Panel question to which you appear to have little insight into the connection between learning the importance of truth telling and putting it into practice two weeks later and also your lack of insight into the standards required of a medical practitioner. The Panel is not satisfied that you will not repeat this misconduct in the future.

…

The Panel considers that a profession's most valuable asset is its collective reputation and the confidence it inspires in members of the public. It has therefore also borne in mind the words of Lord Bingham, Master of the Rolls, in the case of Bolton v Law Society [1994] 2 All ER 486, quoted in the Privy Council case of Dr Gupta [2002] ICR 785 …

'The reputation of the profession is more important than the fortunes of any individual member. Membership of a profession brings many benefits, but that is part of the price.'

The Panel is seriously concerned by the number of acts of dishonesty committed by you, which span a significant period and which represent a serious breach of trust. It is with regret that the Panel has concluded that your integrity cannot be relied upon and thus suspension would be neither proportionate nor appropriate in this case. The Panel regards your misconduct as being fundamentally incompatible with continuing to be a registered medical practitioner.

Accordingly the Panel has determined that your name be erased from the Medical Register."

32. I find it quite impossible to say that the Panel was "wrong" or that it took into account irrelevant factors or that the outcome was disproportionate in relation to the various examples of dishonesty which the Panel had before it. In all the circumstances, the appeal must be dismissed.