Dr Touseef Safdar v General Medical Council

Mrs Justice Steyn : Introduction

1. On 20 February 2025, a Medical Practitioners Tribunal (‘the Tribunal’) found that Dr Touseef Safdar’s fitness to practise was impaired by reason of the serious misconduct (in the form of dishonesty) which it found proved against him. On 24 February 2025, the Tribunal directed that Dr Safdar’s name should be erased from the medical register. Dr Safdar appeals against the sanction imposed by the Tribunal, pursuant to s.40 of the Medical Act 1983 . There is no appeal against the Tribunal’s findings of misconduct or impairment of fitness to practise.

2. Dr Safdar was awarded his primary medical qualification in 2003 by Semmelweis Orvostudomanyi Eyetem. He qualified as a General Practitioner (GP) in 2009. In 2019, at the time of the events which constitute the misconduct, he was practising as a single handed GP. He was subject to an interim suspension order from January 2022 until September 2022 , following which he worked as a locum GP. The initial imposition of an interim suspension order was based on inaccurate information supplied by a third party. When the error was identified, the GMC agreed to an early review of Dr Safdar’s suspension. In June 2020, the suspension was maintained in circumstances where it was alleged he had been working while suspended (an allegation that was ultimately found not proven).

3. At the outset of the hearing I made an anonymity, reporting restriction and third party non-disclosure order to protect the identity of the person referred to in the Tribunal’s determinations, and this judgment, as “ Ms A ”; and to restrict access to sensitive information. These derogations from open justice were the minimum necessary to ensure Ms A’s rights under article 8 of the European Convention on Human Rights are respected. This judgment is supplemented by a Confidential Schedule. I have referred in this judgment to the public record of the Tribunal’s determination. It is a redacted version of the private record to which I have referred in the Confidential Schedule to this judgment. Redactions in the public record are marked “XXX”.

4. The hearing before the Tribunal took place between 4 and 24 February 2025. For the purpose of this appeal, the relevant allegations were that: Allegations 1-3 were not proved. “4. On 26 February 2019 you were interviewed by a XXX adviser and stated that Ms A had XXX the procedure detailed in Confidential Schedule 1 (‘the Procedure’).

5. On or around 25 March 2019 you completed a XXX with the name outlined in Confidential Schedule 2 (‘the Form’) and you stated on the form ‘it was apparent to me that [Ms A] had XXX [the Procedure]’.

6. When you: a. made the statement referred to at paragraph 4; b. completed the Form; you knew that: i. Ms A had not XXX the Procedure; ii. making the statement and/or completing the form could potentially benefit your applications in the XXX proceedings and/or undermine Ms A’s evidence in the same proceedings.

7. Your conduct at paragraphs 4 and 5 were [sic] dishonest by reason of paragraph 6.” Those allegations were found proved, paragraphs 4 and 5 having been admitted and 6 and 7 having been denied.

5. Dr Safdar contends that the imposition of the sanction of erasure (rather than suspension) was wrong in that it was neither necessary nor appropriate in the public interest, and it was excessive and disproportionate. He submits the Tribunal arrived at its conclusion without putting the misconduct into its proper context, failing to give sufficient weight to the “ highly unusual features ” of the case; and erroneously concluding that he did not currently have insight into his misconduct and that there was more than a theoretical risk of repetition. The appellant relies on the General Medical Council’s published guidance to tribunals on imposing sanctions on a doctor’s registration (‘the Sanctions Guidance’). He contends that the Tribunal failed to impose the least severe sanction necessary to protect the public interest, as advised in the Sanctions Guidance, and failed to recognise that the factors listed in that guidance suggesting that a period of suspension may be appropriate were all present.

6. The GMC opposes the appeal, submitting that the Tribunal gave a well-reasoned, thoughtful and balanced determination and correctly concluded that erasure was the appropriate sanction. Appeal by way of re-hearing

7. The approach to be taken by the High Court on an appeal against sanction brought pursuant to s.40 was considered by the Court of Appeal in Sastry v General Medical Council [2021] 1 WLR 5029 , [102]. The court must decide whether the sanction imposed was appropriate and necessary in the public interest or was excessive and disproportionate. The jurisdiction of the court is appellate, not supervisory.

8. The appeal is by way of re-hearing (CPR PD 52, para 19.1(1)) and “ the court is fully entitled to substitute its own decision for that of the tribunal ”. The appellate court “ will not defer to the judgment of the tribunal more than is warranted in the circumstances ”: Sastry , [102]. Where the misconduct consists of dishonesty, the appellate court is well placed to assess what is needed to maintain the reputation of the profession and is less dependent on the expertise of the tribunal than where the misconduct relates to professional performance.

9. However, as Warby J observed in R (Dutta) v General Medical Council [2020] EWHC 1974 (Admin) , [21(1)]: “ The appeal is not a re-hearing in the sense that the appeal court starts afresh, without regard to what has gone before, or (save in exceptional circumstances) that it re-hears the evidence that was before the Tribunal. ” An appellate court asked to interfere with findings of fact made by a tribunal may only do so in limited circumstances. Although the court has the same documents as the Tribunal, the oral evidence is before this court in the form of transcripts rather than live evidence. The appellate court must bear in mind the advantages which the Tribunal has of hearing and seeing the witnesses and should be slow to interfere. See Gupta v General Medical Council [2001] UKPC 61 , [2002] 1 WLR 1691 , [10]. Good Medical Practice

10. The guidance entitled Good Medical Practice published by the GMC provides: “65 You must make sure that your conduct justifies your patient’s trust in you and the public’s trust in the profession. … 71 You must be honest and trustworthy when writing reports, and when completing or signing forms, reports and other documents. You must make sure that any documents you write or sign are not false or misleading. a You must take reasonable steps to check the information is correct. b You must not deliberately leave out relevant information. 72 You must be honest and trustworthy when giving evidence to courts or tribunals. You must make sure that any evidence you give or documents you write or sign are not false or misleading. a You must take reasonable steps to check the information is correct. b You must not deliberately leave out relevant information.” The Sanctions Guidance

11. The Sanctions Guidance in use from 5 February 2024 states at paragraph 14: “The main reason for imposing sanctions is to protect the public. This is the statutory overarching objective, which includes to: a protect and promote the health, safety and wellbeing of the public b promote and maintain public confidence in the medical profession c promote and maintain proper professional standards and conduct for the members of the profession.” This reflects s.1 (1A) of the Medical Act 1983 . Throughout the Sanctions Guidance, reference to “ protecting the public ” encompasses each of these three parts of public protection: Sanctions Guidance, paragraph 15.

12. Under the heading “ Maintaining public confidence in the profession ”, paragraph 17 of the Sanctions Guidance states: “Patients must be able to trust doctors with their lives and health, so doctors must make sure that their conduct justifies their patients’ trust in them and the public’s trust in the profession (see paragraph 81 of Good medical Practice ) . Although the tribunal should make sure the sanction it imposes is appropriate and proportionate, the reputation of the profession as a whole is more important than the interests of any individual doctor.” The latter point reflects the observations of Sir Thomas Bingham MR in Bolton v Law Society [1994] 1 WLR 512 , at 519B-E.

13. In deciding what sanction, if any, to impose the tribunal should consider the sanctions available, starting with the least restrictive, and it should have regard to the principle of proportionality. However, once the tribunal has determined that a certain sanction is necessary to protect the public, and is therefore the minimum action required to do so, that sanction must be imposed: Sanctions Guidance, paragraphs 20-21.

14. Where a tribunal finds a doctor’s fitness to practise is impaired by reason of misconduct, it can (a) take no action; (b) agree to accept undertakings that have been agreed between the doctor and the GMC; (c) impose conditions on the doctor’s registration for up to three years; (d) suspend the doctor’s registration for up to 12 months; or (e) erase the doctor's name from the medical register: Sanctions Guidance, paragraph 66. If the sanction of erasure is imposed, the doctor “ cannot apply to be restored to the medical register until five years have elapsed ”: Sanctions Guidance, paragraph 111.

15. In relation to suspension, the Sanctions Guidance states: “92 Suspension will be an appropriate response to misconduct that is so serious that action must be taken to protect members of the public and maintain public confidence in the profession. A period of suspension will be appropriate for conduct that is serious but falls short of being fundamentally incompatible with continued registration (ie for which erasure is more likely to be the appropriate sanction because the tribunal considers that the doctor should not practise again either for public safety reasons or to protect the reputation of the profession). … 97 Some or all of the following factors being present (this list is not exhaustive) would indicate suspension may be appropriate . a A serious breach of Good medical practice , but where the misconduct is not so difficult to remediate that complete removal from the register is in the public interest . However, the departure is serious enough that a sanction lower than a suspension would not be sufficient to protect the public. … e No evidence that demonstrates remediation is unlikely to be successful, eg because of previous unsuccessful attempts or a doctor's unwillingness to engage. f No evidence of repetition of similar behaviour since incident. g The tribunal is satisfied the doctor has insight and does not pose a significant risk of repeating behaviour. ” (Emphasis added.)

16. Erasure should only be imposed where this is “ the only means of protecting the public ”: Sanctions Guidance, paragraph 107. The Sanctions Guidance states: “108 Erasure may be appropriate even where the doctor does not present a risk to patient safety, but where this action is necessary to maintain public confidence in the profession. For example, if a doctor has shown a blatant disregard for the safeguards designed to protect members of the public and maintain high standards within the profession that is incompatible with continued registration as a doctor. 109 Any of the following factors being present may indicate erasure is appropriate (this list is not exhaustive). a A particularly serious departure from the principles set out in Good medical practice where the behaviour is difficult to remediate. b A deliberate or reckless disregard for the principles set out in Good medical practice and/or patient safety. c Doing serious harm to others (patients or otherwise), either deliberately or through incompetence and particularly where there is a continuing risk to patients … d Abuse of position/trust (see Good medical practice, paragraph 81: ‘You must make sure that your conduct justifies your patients’ trust in you and the public’s trust in the profession’). e Violation of a patient’s rights/exploiting vulnerable people … f Offences of a sexual nature, including involvement in child sex abuse materials … g Offences involving violence. h Dishonesty, especially where persistent and/or covered up (see guidance below at paragraphs 120–128). i Putting their own interests before those of their patients … j Persistent lack of insight into the seriousness of their actions or the consequences.”

17. Dishonesty is addressed in the Sanctions Guidance at paragraphs 120-128 and includes the following: “124 Although it may not result in direct harm to patients, dishonesty related to matters outside the doctor’s clinical responsibility (eg providing false statements or fraudulent claims for money) is particularly serious. This is because it can undermine the trust the public place in the medical profession. Health authorities should be able to trust the integrity of doctors, and where a doctor undermines that trust there is a risk to public confidence in the profession. Evidence of clinical competence cannot mitigate serious and/or persistent dishonesty. … 128 Dishonesty, if persistent and/or covered up, is likely to result in erasure…”

18. The Sanctions Guidance addresses the issue of insight as a potential mitigating factor, at paragraphs 45-49, and as a potential aggravating factor at paragraphs 51-53. The Sanctions Guidance states: “ The doctor’s insight into the concerns 45 Expressing insight involves demonstrating reflection and remediation. 46 A doctor is likely to have insight if they: a accept they should have behaved differently (showing empathy and understanding) b take timely steps to remediate (see paragraphs 31-33) and apologise at an early stage before the hearing c demonstrate the timely development of insight during the investigation and hearing. … Lack of insight 51 It is important for tribunals to consider insight, or lack of it, when determining sanctions. … 52 A doctor is likely to lack insight if they: a refuse to apologise or accept their mistakes b promise to remediate, but fail to take appropriate steps, or only do so when prompted immediately before or during the hearing c do not demonstrate the timely development of insight d fail to be open and honest during the hearing (see paragraph 98 of Good medical practice )”.

19. Remediation is described as being “ where a doctor addresses concerns about their knowledge, skills, conduct or behaviour ”. The Sanctions Guidance notes at paragraph 32: “However, there are some cases where a doctor’s failings are difficult to remediate. This is because they are so serious that despite steps subsequently taken, there remains a current and ongoing risk to public protection and action is needed to maintain public confidence. This might include where a doctor knew, or ought to have known, they were causing harm to patients, and should have taken steps earlier to prevent this.” Case-law regarding dishonesty and insight

20. Both parties relied on Abbas v GMC [2017] EWHC 51 (Admin) , in which Nicol J dismissed an appeal against the sanction of erasure, as well as against the findings of misconduct and impairment, in the context of a case concerning several categories of misconduct, the most serious of which amounted to dishonesty ([45]).

21. Nicol J observed: “32. Understandably, in the context of deciding what sanction is appropriate, a finding of dishonesty is of particular significance, especially if it is persistent and combined with a lack of insight. In such circumstances, ‘nothing short of erasure is likely to be appropriate’ – see Naheed v GMC [2011] EWHC 702 (Admin) at [22] per Parker J. Plainly, the individual circumstances of the case must be considered and there can be no universal or inflexible rules in this context. As Blake J said in Atkinson v GMC [2009] EWHC 3636 (Admin) at [13], ‘erasure is not necessarily inevitable and necessary in every case where dishonest conduct by a medical practitioner has been substantiated. There are cases where the panel, or indeed the court on appeal, have concluded in the light of the particular elements that a lesser sanction may suffice and it is the appropriate sanction bearing in mind the important balance of the interests of the profession and the interests of the individual. It is likely that for such a course to be taken, a panel would normally require compelling evidence of insight and a number of other factors upon which it could rely that the dishonesty in question appeared to be out of character or somewhat isolated in its duration or range, and accordingly there was the prospect of the individual returning to practice without the reputation of the profession being disproportionately damaged for those reasons.’ …

49. As the authorities I have cited make clear, where, as in this case, there has been persistent dishonesty, erasure is a likely sanction. It may be otherwise if there is insight or some other combination of circumstances which would mean a lesser sanction would be appropriate. However, as Mr Mant said, in the present case the Tribunal found that the Appellant lacked any insight into his errors. Putting the matter at its lowest, I could not possibly say that erasure was not a sanction open to the Tribunal. The Appellant argued that there may be different degrees of wrongdoing, meriting different levels of sanction. Of course that is right. It is also right, as the Tribunal acknowledged, that the Appellant was previously of good character. However, on the findings that the Tribunal made and was entitled to come to, he had been dishonest, not just on one occasion, but on a number of them and over a considerable period. He had dishonestly misled the IOP and he had dishonestly breached conditions on his registration. In those circumstances, it would have been surprising if the Tribunal had concluded that a lesser sanction than erasure was appropriate.”

22. On the approach to insight, my attention was drawn to Karwal v GMC [2011] EWCA Civ 826 , [11], Yusuff v GMC [2018] EWHC 13 (Admin) , [18], and Sawati v GMC [2022] EWHC (Admin) 283, [94] (citing Sayer v General Osteopathic Council [2021] EWHC 370 (Admin) , (2021) 182 BMLR 164, [25]). In Sayer , at [25], Morris J considered numerous authorities regarding the relationship between contesting charges and insight, and drew the following principles: “(1) Insight is concerned with future risk of repetition. To this extent, it is to be distinguished from remorse for the past conduct. (2) Denial of misconduct is not a reason to increase sanction : Awan [ . [2020] EWHC 1553 (Admin) ] §38 (3) It is wrong to equate maintenance of innocence with lack of insight. Denial of misconduct is not an absolute bar to a finding of insight. Admitting misconduct is not a condition precedent to establishing that the registrant understands the gravity of the offending and is unlikely to repeat it : Motala [ [2017] EWHC 2923 (Admin) ] §34 and Awan §38. (4) However attitude to the underlying allegation is properly to be taken into account when weighing up insight : Motala §34 Where the registrant continues to deny impropriety, that makes it more difficult for him to demonstrate insight. The underlying importance of insight and its relationship with denial of misconduct was usefully analysed by Andrew Baker J in Khetyar [ [2018] EWHC 813 (Admin) ] (at §49) as follows: ‘Of course, no sanction was to be imposed on him for his denials as such; however, insight requires that motivations and triggers be identified and understood, and if that is possible at all without there first being an acceptance that what happened did happen it will be very rare, and any assessment of ongoing risk must pay close attention to the doctor's current understanding of and attitude towards what he has done.’ (5) The assessment of the extent of insight is a matter for the tribunal, weighing all the evidence and having heard the registrant. The Court should be slow to interfere : Motala §§30 and 31.” Tribunal’s findings of fact

23. I have outlined the facts in the Confidential Schedule.

24. The Tribunal found Ms A’s evidence in relation to the Procedure to be “ consistent and reliable ”. It was also consistent with the evidence of Dr B and Dr C, who were “ compelling witnesses ”. Whereas Dr Safdar’s evidence on this matter “ shifted ”, and was “ inconsistent ” and “ unreliable ”.

25. The Tribunal found allegations 6 and 7 proven. The Tribunal determined that at the time he made the statement referred to at paragraph 4 of the Allegation and completed the Form referred to at paragraph 5 of the Allegation, Dr Safdar knew what he wrote was untrue. It was “ inconceivable that Dr Safdar had seen what he described in his evidence ”. The Tribunal determined that Dr Safdar could not “ reasonably ” or “ genuinely ” have believed his statements relating to Ms A and the Procedure. The “ only plausible explanation ” for making them was “ to potentially benefit Dr Safdar’s Applications in XXX and or to undermine Ms A’s evidence in the same proceedings ”. The Tribunal determined that his conduct would be regarded as dishonest by the standards of ordinary decent people.

26. The Tribunal noted that Dr Safdar “ repeated and expanded on the allegations regarding the Procedure between February 2019 and June 2019…, whilst at all times he knew them to be false ”, only withdrawing them when faced with incontrovertible evidence from Dr B. The Tribunal considered that “ Dr Safdar had exploited his position as a doctor to lend credibility to false assertions ”. He “ deliberately used language and medical terms to lend credibility to allegation that he knew to be false ”, and “ omitted to use the correct medical term in any of his statements ”. He did so to “ further his own position ” within the proceedings and “ to undermine Ms A both personally and professionally ”. Tribunal’s Determination on Misconduct and Impairment

27. Having made its findings of fact on 18 February 2025, the Tribunal addressed misconduct and impairment two days later. The Tribunal determined that Dr Safdar’s conduct “ clearly met the threshold of serious misconduct ”, “ falling far below the standard expected of a medical professional ”. They described his “ evolving false narrative ” regarding Ms A as “ a pattern of fabrication ”. He had “ multiple opportunities to correct his dishonesty but failed to do so ”. The Tribunal observed that “ honesty, trustworthiness and integrity are fundamental tenets of the medical profession ” and they considered that his conduct “ would be regarded as deplorable by fellow practitioners and members of the public alike ”.

28. In determining whether a finding of impairment of fitness to practise was necessary, the Tribunal found that Dr Safdar’s misconduct was a breach of the fundamental tenets of the medical profession, had brought the profession into disrepute, and was damaging to public confidence in the profession. The Tribunal acknowledged that he demonstrated good clinical abilities and did not pose a risk to public protection. But “ his dishonesty would have caused significant distress to Ms A ” .

29. The Tribunal “ noted a lack of meaningful reflection or remediation of his dishonesty. In considering Sawati, the Tribunal emphasised that his dishonesty was central to his misconduct, as it was a deliberate act of deception intended to cause harm. ”

30. In his evidence to the Tribunal, Dr Safdar said that in his statements regarding the Procedure, “ with hindsight I should have stated that I believed this could be the case and not expressed as proven fact ”. At the outset of cross-examination of Ms A, Counsel for the appellant referred to Ms A’s statement and said, “ if that statement is correct, and you say it is, through me Dr Safdar wants to apologise to you because that would have caused you distress ”. The Tribunal considered whether these matters were evidence of insight, stating: “95. The Tribunal found that Dr Safdar had always been aware that Ms A had XXX the Procedure. Therefore, it concluded that his apologies, framed conditionally on the continued possibility XXX, held little weight with regards to demonstrating insight.”

31. His remediation efforts “ primarily consisted of CPD, with no targeted steps taken to address concerns about his dishonesty ”. The Tribunal considered that it “ could not rule out the risk of repetition of his dishonest conduct ”, noting that “ there was no evidence before it to demonstrate how Dr Safdar may behave in the future should he face similar pressures or disputes ”.

32. The Tribunal concluded that Dr Safdar’s misconduct was so serious that a finding of impairment was necessary in relation to limbs (b) and (c) of the Overarching Objective. The Tribunal’s Determination on Sanction

33. The Tribunal considered that the nature and circumstances of Dr Safdar’s dishonesty were aggravating features. He “ repeated and elaborated upon ” his false statements, signing a statement of truth, and he did so “ to manipulate the process for his own benefit ”. He “ used his position to undermine Ms A’s evidence causing unacceptable and unnecessary distress, the effects of which were evident before this Tribunal ”; and his actions represented “ an abuse of his position as a doctor ”.

34. Under the heading aggravating and mitigating factors, the Determination states: “129. The Tribunal noted the absence of any evidence on behalf of Dr Safdar to suggest that he has developed any insight into his wrongdoing or taken any steps toward remediation. The Tribunal noted that Dr Safdar has presented various CPD but has not submitted anything that could be insight into his dishonesty.”

35. The Tribunal considered whether suspension would be an appropriate sanction. The Tribunal decided that “ any sanction needed to reflect the seriousness of dishonesty and the difficulties in remediating it ”. The Tribunal considered that there had not been sufficient remorse or regret and there was not sufficient evidence of insight on behalf of Dr Safdar regarding his dishonesty. There was a risk of repetition in the future, albeit a low risk.

36. The Tribunal recorded Counsel for Dr Safdar “ invited the Tribunal to consider the highly unusual features that caused Dr Safdar distress during that period ”. He had faced “ numerous allegations … over a long period of time ”, and had been subject to an interim suspension for two years and nine months. With reference to this submission, the Tribunal stated that “ it did not accept this submission ” and continued: “141. … The Tribunal did not consider it so unusual for a doctor to experience XXX. It did, however, consider that Dr Safdar’s reaction to those proceedings whereby he told a malicious lie with the intention to cause personal and professional harm to another party, XXX, was highly unusual.”

37. The Tribunal described Dr Safdar’s dishonesty as “ deplorable ” and said that his misconduct was “ not only dishonest but also demonstrated a blatant disregard ” for certain matters (described in the Confidential Schedule) “ which exist to protect the public ”, and that he used his knowledge of those matters “ together with his position as a doctor, to paint a false picture ” for his own benefit and to undermine Ms A. The Tribunal concluded that this was a “ particularly serious departure from the principles of Good Medical Practice ”. The Tribunal concluded that Dr Safdar’s misconduct was so serious that suspension would not be sufficient to protect public confidence in the medical profession or to uphold proper stands of behaviour and conduct for members of that profession. No lesser sanction than erasure would be adequate to maintain public confidence and uphold professional standards. The parties’ submissions

38. On behalf of Dr Safdar, Mr Haycroft acknowledged that the Tribunal directed itself properly in relation to the stages and factors to be taken into account. Three errors are alleged concerning, first, the weight the Tribunal gave to what Mr Haycroft identified as “ highly unusual features ” of the case; secondly, the Tribunal’s conclusion that Dr Safdar did not currently have sufficient insight into his misconduct; and, thirdly, the Tribunal’s conclusion that there was more than a theoretical risk of repetition in the case. (a) The “highly unusual features” of the case

39. Mr Haycroft contends that the Tribunal, when expressing their conclusion as identified in paragraph 36 above, misstated and understated the “ highly unusual features ” on which he relied with the consequence that the Tribunal failed to take them sufficiently into account.

40. I have set out the “ highly unusual features ” relied on more fully in the Confidential Schedule. They included that (i) the dishonesty, although over a period of time, arose out of a single, isolated, highly unusual issue; (ii) having never before faced any challenge regarding his probity, over a long period of time the appellant faced numerous allegations, and (iii) had to deal with the stress of addressing them; and (iv) he had to deal with the stress of being subject to interim suspension for 2 years and 9 months.

41. Mr Haycroft submitted that while the Tribunal was right that the feature they referred to when rejecting his submission was not, itself, unusual, they did not address the sustained time he was subject to allegations, the nature of those allegations, or the highly unusual pressure on Dr Safdar as a consequence of the particular circumstances.

42. On behalf of the GMC, Ms Richards KC submits that the Tribunal accurately noted the submission. They did not misstate or misunderstand it. They were entitled to disagree with Mr Haycroft’s characterisation of those features. The Tribunal did not accept that the dishonesty should be treated as confined in the way contended for, concluding that it was a pattern of fabrication. Having regard to the chronology, the dishonesty occurred prior to some of the features relied on, including the interim suspension (which was imposed in January 2020). Such subsequent matters are incapable of providing any explanation for the dishonesty. The Tribunal had heard Dr Safdar give oral evidence. His Counsel’s hypothesis as to how the misconduct might have arisen was not supported by any evidence from Dr Safdar, and (as explained further in the Confidential Schedule) it was not consistent with the evidence he gave. Dr Safdar did not give evidence that his (dishonest) statements were a reaction to the stress of facing allegations, nor to the effect that it was a “ moment of madness ” at a time of stress. (b) Insight

43. The appellant contends that the Tribunal’s conclusion that there was not sufficient evidence of insight (see paragraphs 31, 34 and 35 above) is very close to incorrectly equating insight with an admission of guilt, contrary to the authorities to which I have referred in paragraph 22 above.

44. Mr Haycroft submits that Dr Safdar knows what is right and wrong, knows that dishonest conduct should not occur, and that the misconduct found proven in this case is serious. He submits that Dr Safdar “ understands the gravity of the offending and is unlikely to repeat it ”. While he does not agree with them, Dr Safdar accepted the Tribunal’s findings, and he accepted that it followed that misconduct and impairment to practise had been established. Many doctors would have remained neutral on those issues and Mr Haycroft contends that Dr Safdar’s concessions were compelling evidence of insight, showing he understood the gravity of the misconduct found against him.

45. Any residual issue on insight should have been a matter for reflection prior to a review hearing in the future. Such further insight could develop over time. The appellant was not given an opportunity to reflect as the third stage of the hearing followed swiftly after the findings against him.

46. Ms Richards contends that the Tribunal correctly directed themselves on the authorities regarding insight, and there is no basis on which the decision can fairly be read as indicating that they equated insight with an admission of guilt. There was little evidence of insight. The only concrete matter to which he could point, apart from the “ apology ” which the Tribunal correctly characterised as conditional, was the fact that, in light of the Tribunal’s findings of fact, he did not dispute misconduct or impairment. Given the Tribunal’s findings of fact, there was no realistic possibility of them reaching any other finding, so his concessions provide little evidence of insight. None of the written or oral evidence given by Dr Safdar demonstrated any empathy or understanding, or provided any foundation for a positive finding of insight. A mere assertion by Dr Safdar’s Counsel that he knows right from wrong, and knows that dishonesty is serious, was not an adequate foundation for a positive finding of insight. The approach contended for by the appellant is superficial and simplistic. (c) Risk of repetition

47. Mr Haycroft submits that in assessing the risk of repetition, the Tribunal failed to take into account the appellant’s previous history of probity and the lack of any repetition of any misconduct in the ensuing almost seven years, despite the enormous stresses on him during that period, including by reason of the interim suspension and the GMC investigation. In his oral submissions, he acknowledged that it was not possible to say there was no risk, but the low risk was no more than a theoretical risk.

48. Ms Richards contends that the Tribunal dealt with this in a modest and proportionate way. In circumstances where he had engaged in a pattern of fabrication for cynical and malicious reasons, and there was nothing to show true insight or remediation, they could not rule out the risk of repetition. Nonetheless, they characterised the risk of repetition as low. They made no error in reaching that conclusion. Decision

49. I reject the contention that the Tribunal failed to give sufficient weight to the “ highly unusual features ”. The Tribunal’s summary of the appellant’s submission was accurate: it did not misstate or understate it. In any event, reliance on a summary of a submission to contend that the Tribunal did not properly understand it is misplaced, at least in a case such as this where what was relied on was a central element of the facts which they plainly fully understood and took into account.

50. As the respondent has correctly identified, those elements of the “ highly unusual features ” (including interim suspension) which were subsequent to the dishonesty are irrelevant when considering what, if any, explanation there was for his misconduct. There was no explanation from Dr Safdar who maintained he had not been dishonest. The Tribunal were not wrong to reject Counsel’s characterisation of the circumstances in which Dr Safdar found himself, or the pressures that he was under, as being highly unusual circumstances or pressures for a medical professional to face. The constitution and experience of the Tribunal is such that they were well-placed to make that assessment. The features relied on did not materially diminish the gravity of Dr Safdar’s misconduct. Moreover, Counsel’s hypothesis that Dr Safdar’s misconduct was the result of the stressful and distressing situation he found himself in is contrary to the Tribunal’s conclusion that his actions were deliberate and his motive was malicious.

51. The Tribunal’s finding that there was insufficient evidence of insight is impeccable. I agree with Ms Richards that they correctly directed themselves, and there is no foundation for the contention that they equated Dr Safdar’s denial of guilt with lack of insight. They recognised that denial of misconduct is not an absolute bar to a finding of insight. But where the misconduct was intentional - as it was here, consisting of repeated and malicious dishonesty - it is very difficult to remediate, and to show that what motivated and triggered the misconduct has been identified and understood, without an acceptance that what happened did happen. An abstract understanding that dishonesty is wrong is to be expected of any registrant: in and of itself it does not show insight on Dr Safdar’s part regarding his dishonesty .

52. The Tribunal considered what evidence there was of insight, and there was very little indeed. The value of the “ apology ” conveyed by Counsel was slight. It was no more than an acknowledgment that if Dr Safdar’s statements (which he knew to be untrue) were incorrect, they would have caused Ms A distress. Even on that contingent basis, the acknowledgment of the impact on Ms A was very limited, failing to touch on the scale and multiple causes of the distress (as I explain further in the Confidential Schedule).

53. Although I accept that some doctors might have remained neutral on the question whether misconduct and impairment were established, the clarity and strength of the Tribunal’s findings of fact were such that Dr Safdar would have been well aware, when conceding that misconduct and impairment were established, that there was no prospect of the Tribunal finding otherwise.

54. The Tribunal heard Dr Safdar give evidence. There is nothing in his written or oral evidence on which the appellant can rely to demonstrate empathy or insight. Nor had he taken, or prospectively identified, any steps by way of remediation. By the time of the hearing regarding sanction, Dr Safdar had been aware of the Tribunal’s findings for a week. Although it would have been difficult to do so, it would have been open to him to give further evidence at the sanction stage if he had wished. I am wholly unpersuaded that the Tribunal made any error in concluding that there was not sufficient evidence of insight.

55. The Tribunal’s assessment that the risk of repetition of dishonest conduct was low but could not be ruled out was reasonable and moderate in circumstances where he had not shown insight into the triggers and motivations for his misconduct. The Tribunal did not overstate the risk or ignore Dr Safdar’s previous good character or his behaviour subsequent to the misconduct.

56. The appellant is right that there is a spectrum of dishonesty. But the difficulty for him is that his dishonesty was towards the most serious end of the spectrum. The Tribunal were clearly correct in their assessment that Dr Safdar’s dishonesty was repeated and maintained over several months. Their finding that Dr Safdar put forward an “ evolving false narrative ”, engaging in “ a pattern of fabrication ”, is unimpeachable. This was not an isolated incident. The gravity of his dishonesty was exacerbated by the circumstances in which his statements were made (as explained more fully in the Confidential Schedule), his aim of benefitting himself and harming Ms A, and his abuse of his position as a doctor.

57. The Tribunal were clearly entitled, and in my view undoubtedly correct, to decide that public confidence in the medical profession would be undermined if they imposed any lesser sanction for Dr Safdar’s very serious dishonesty than erasure. I recognise of course that the sanction of erasure has a crushing impact on Dr Safdar; but as the Sanctions Guidance indicates, the Tribunal had to keep in mind that the maintenance of public confidence in the medical profession is more important than the effects of a sanction upon an individual doctor. There is in my judgment no basis on which it could be said that the challenged decision of the Tribunal was wrong. Conclusion

58. It follows that this appeal fails and is dismissed.