Uruakpa v General Medical Council [2010] EWHC 1302 (Admin)

Case No CO/10699/2009[2010] EWHC 1302 (Admin)
IN THE HIGH COURT OF JUSTICE
QUEEN'S BENCH DIVISION
THE ADMINISTRATIVE COURT
Venue Royal Courts of JusticeDate Thursday, 13 May 2010
Strand
London WC2A 2LL
B e f o r e:
MR JUSTICE SAUNDERS
Between
URUAKPAAppellantv
Between
GENERAL MEDICAL COUNCILRespondent
Computer-Aided Transcript of the Stenograph Notes ofWordWave International LimitedA Merrill Communications Company165 Fleet Street London EC4A 2DYTel No: 020 7404 1400 Fax No: 020 7404 1424(Official Shorthand Writers to the Court)
DR URUAKPA appeared In Person for in personMS G WHITE appeared for Respondent
J U D G M E N T
[1]MR JUSTICE SAUNDERS: This appeal has been brought under section 40 of the Medical Act 1983 ("the 1983 Act") against the direction on 21 August 2009 of a Fitness to Practice Panel of the respondent ("the panel") that the Appellant's name should be suspended from the medical register for a period of 12-months.[2]Section 40 of the 1983 Act provides for an appeal to the High Court against that decision and I can dismiss or allow the appeal. If I allow the appeal, I can substitute for the direction any other direction that the Panel had the power to make, or remit the matter to the panel to dispose of the case in accordance with my directions. The appeal is also governed by part 52 of the Civil Procedure Rules 1998. Part 52.11 of those Rules provides that the appeal court will allow an appeal where the decision of the lower court was wrong or unjust or because of a serious procedural or other irregularity in the proceedings in the lower court.[3]I have been referred by the respondent to several authorities in the Court of Appeal which set out how I should exercise my jurisdiction in considering this appeal. I have considered and applied that guidance. The principles are not in dispute and I need only refer to part of the head note from the case of Meadow v General Medical Council [2007] QB 462, which reads as follows:
"An appeal ... from a decision of a Fitness to Practice Panel was not limited to a review of the Panel's decision and might take the form of a re-hearing. Whether the appeal was by way of review or a re-hearing, the court would not interfere with the Panel's decision unless persuaded that ... its imposition of a sanction was wrong."
[4]Further, I have taken into account the observation of Thorpe LJ in that case, which is similar to observations in other cases that: "Where the charge ... relates to clinical work, the appellate court must accord deference to the evaluation of a Panel composed of doctors".[5]The procedure for the investigation of allegations against doctors, reference to a panel and the way in which that reference is to be considered, is set out in the General Medical Council (Fitness to Practice) Rules 2004 ("the Rules"). I am satisfied that these Rules were the appropriate Rules in force at the time of these proceedings and that the panel were correct to apply them. I say that because, in the course of submissions, reference was made to the GMC (Professional Performance) Rules 1997. The respondent has satisfied me that it was the 2004 Rules that operated in relation to this panel and superseded the earlier Rules.[6]I have not heard oral evidence, although I have allowed the Appellant considerable latitude by allowing him to give evidence in the course of submissions. I have a very long witness statement from the Appellant and a statement from the solicitor who instructed counsel on the original hearing on behalf of the respondent. In addition, I have been referred to the transcript of the proceedings before the Panel and a large number of other documents.[7]The background is not contentious. The Appellant qualified and trained as a doctor in Nigeria and Australia. He came to the United Kingdom in 1997. He was granted full registration by the respondent in December 2003. The particular area of medicine in which the Appellant practised was obstetrics and gynaecology and he has worked in those departments at a number of hospitals in a number of different locations.[8]Allegations as to the Appellant's work were referred to the respondent by the National Clinical Assessment Service ("NCAS") in 2005. Although all the allegations were not supplied to the respondent immediately, they concerned work which the Appellant had done for relatively short periods at the Nevill Hall Hospital in Abergavenny and the Cheltenham General Hospital. It is not necessary to consider the allegations in detail at this stage but they related to the conduct of operations, his performance on call, poor communication skills with patients and misdiagnosis. NCAS made the reference, which they described as exceptional, because they were concerned that patient safety may be compromised by the Appellant continuing to practice without restriction.[9]As a result of those allegations, the respondent, on 28 July 2005, exercised its powers to make an interim order imposing conditions on the Appellant's registration. The interim order initially lasted for 18-months. It was extended by the High Court on a number of occasions and remained in force until the decision of the Panel in August 2009. Both Collins J and Beetson J, when granting extensions, criticised the respondent for the delay in setting up a Panel hearing, which was caused by the failure of the respondent to give sufficient details of the allegations for the Appellant to deal with them. It is suggested by the respondent that that is irrelevant to this hearing because, by the time the Panel held a hearing, full details had been given. Largely, I accept that submission, but there is no doubt that the imposition of the conditions made it very difficult for the Appellant to get a job and clearly, as he accepts, a period not practising inevitably affected his ability to get back into work. That was, therefore, in itself a considerable sanction. Throughout those hearings in the High Court, the Appellant indicated a clear intention to challenge the allegations which were made against him.[10]By letter dated 20 February 2006, the respondent asked the Appellant to agree to an assessment of his professional performance being carried out. The respondent has the power to do this under Rule 7(3). By letter dated 20 March 2006, the Appellant agreed, although he did suggest that his case should be referred back to NCAS or the assessment should await his application for judicial review. By letter dated 28 September 2006, the Appellant informed the respondent that he would not undergo the assessment. He gave as his reasons for that legal advice, his concerns and complaints about the GMC proceedings, and his entitlement to a fair hearing. As a consequence of that letter, the respondent referred the Appellant's case to a Panel. The respondent had a discretion to do that under Rule 7(6) and, in my judgment, they were justified in exercising their discretion in that way. In the light of the allegations it was clearly, in my judgment, an appropriate and proportionate response to request the assessment, and the letter of 28 September 2006 did not provide any reasonable excuse for refusal.[11]The hearing did not take place until August 2008. Part of the reason for that was that the Appellant asked for, and was granted, an adjournment on two occasions, the second of which was so that he could undertake the performance assessment which he had previously refused to do. On 28 March 2008, the Appellant changed his mind again and refused to be assessed. His reasons were criticisms of the structure of the test and that they were unfair; that the case should have been referred back to local procedures, and, because of the period that he had been out of work, the assessment was unreasonable and unfair and a breach of Article 6. He also strongly disputed the allegations which had started this procedure.[12]The Appellant repeated his criticisms of the assessment to me in his submissions. His case is that the best method of testing medical knowledge is by extended matching multiple choice questions. He is supported in this by a letter which the Appellant sent to the respondent from Professor David Wall who was the Deputy Regional Post Graduate Dean for the West Midlands. I am satisfied that the respondent, in setting the test, acted on academic advice in setting the requirement for the assessment and, while it appears to be true that the Royal College of Obstetricians were not consulted while other Royal Colleges were, that does not, in my judgment, invalidate the assessment. The tests are devised by a specialist group attached to University College London and, I have no reason to doubt, are perfectly adequate to test the requisite knowledge. It is for the respondent to decide what is the appropriate way to test medical competences not the High Court and, in my judgment, it cannot be reasonable for a doctor to refuse to take the test on the basis that he does not think the test is well designed. The Appellant had previously obtained an adjournment on the basis that he would do the test. He asked for that, no doubt, knowing the nature of the test.[13]The hearing before the Panel started on 4 August 2008 and lasted for 8 days, but there were a number of adjournments during those days including a complete day when the Panel did not sit to allow for preparation work to be done. The Appellant was unrepresented. He arrived on Day 1 with a very large number of documents, all of which had to be photocopied and considered by the respondent. There were a number of preliminary issues which the Appellant took. He wished to go to the High Court to enforce witness summonses which had not been obeyed. The Panel refused to adjourn for that purpose. They did that because a number of the witnesses were already going to be called by the respondent, others they regarded as irrelevant, and the evidence of one was a duplication of evidence to be called by another. These were case management decisions which the Panel were perfectly entitled to make to keep the case within reasonable bounds. The Appellant then wished to apply for a stay because it was argued that the respondent had abused the process. The Appellant was directed to produce a skeleton argument identifying the evidence upon which he intended to rely to support his argument. The Panel took the view that the skeleton the Appellant produced failed to identify the evidence.[14]The Appellant complained that he was, in effect, being bullied by the Chairman, the Legal Assessor and counsel for the respondent. "Bullied" is my word, but I believe it accurately summarises the Appellant's evidence. I have looked with care at the parts of the transcript that the Appellant has asked me to look at. Undoubtedly the hearing was made much more difficult by the fact that the Appellant was unrepresented. The hearing was in danger of overrunning. The Panel and their Legal Assessor were entitled to try and establish just what the Appellant's arguments were. They had to seek to clarify the issues. It maybe that a degree of frustration set in as it proved difficult to achieve clarity but, having considered the transcript, I am satisfied that there is no substance in the Appellant's claim that he was bullied. Both the Chairman and the Legal Assessor sought to clarify what exactly the Appellant was saying and wished to argue, but they did do their best to assist the Appellant to present his case. The Appellant himself, at one stage, accepted that he was being treated perfectly well.[15]The relevance of all this is that, at the beginning of day six, the Appellant withdrew his application for a stay and admitted some of the allegations made against him. The respondent then withdrew the other allegations, so leaving no live issue to be tried. The Appellant says that he did not make those admissions of his own free will but because of bullying by the Chairman and Legal Assessor, and also as a result of things said privately by counsel for the respondent. According to the Appellant, at the end of day three, there was a discussion between the Chairman, the Legal Adviser and the Appellant, in which the Chairman was rude to him. The passages on which the Appellant relies are to be found in the transcript of day three, pages 14 to 21. The exchanges related to a skeleton argument produced by the Appellant at a the instigation of the Panel, setting out the basis for his application to stay the hearing as being an abuse of process. The complaint from the Chairman was that it did not do what the Appellant had been asked to do, that was to identify clearly the facts on which he relied to support his argument.[16]According to the Appellant, and this is to be found at paragraph 289 of his statement, the respondent's counsel sympathized with the Appellant and said as they left for the day "that lot felt they could get away with such behaviour because both of us are foreigners", and warned him of "imminent train crash". The significance of all this is that the Appellant asserts that it was because of the behaviour of the Committee that he came to an agreement with the respondent that he would admit certain charges and the Respondent would not pursue others. He says, essentially, that the admissions were not made of his own free will and, therefore, should not be relied on.[17]Mr Turner, who was the solicitor instructing counsel at the hearing, portrays a completely different picture. He says, in his view, the Chairman was not hostile but went out of his way to give the Appellant every opportunity to put his case. He did not overhear any such conversation with counsel and says that all the negotiating was conducted with great courtesy.[18]I have considered the appropriate parts of the transcript. I am quite satisfied that, from the point of view of an objective observer, the Appellant was treated with considerable patience by the Panel. They did give him every opportunity to put his case in a comprehensible way. I also have little doubt that there were occasions, and perhaps in particular the one to which the Appellant has referred, when that patience came close to running out. The Appellant had not done what the Panel had asked him to do and had provided him with time to do. No doubt the Appellant was not being deliberately obstructive but was finding it difficult to do what he was asked to do.[19]I have no statement from Mr Lambis, who was counsel representing the respondent. The respondent asked for the opportunity to get evidence from him if I was going to attach any weight to this point. I will not give that opportunity and will assume for the purposes of this judgment that words such as those alleged were said by Mr Lambis. There has been plenty of opportunity for the respondent to get this evidence. In those circumstances, I will assume that Mr Lambis was also of the view that the Chairman had gone further than was appropriate at that stage of the hearing. I have also no doubt that the Appellant, representing himself, found the whole experience daunting and it put great strain on him. However, that does not in anyway mean that either I or the Panel should attach no or limited significance to the admissions which he made.[20]The Appellant is an intelligent, professional man. He knew full well what the significance of the hearing was and what he was admitting and the consequences of what he was admitting. He took that decision and while, no doubt, he was under pressure, the decision to make the admission that he did was made of his own free will.[21]After the Panel had made a finding that the Appellant's fitness to practice was impaired, the case was adjourned until the following April, for reasons which I will need to deal with later. At that adjourned hearing the Appellant said that he wanted to argue that there was an abuse of the proceedings in the way he had been treated by the respondent, and that he had been deceived into entering into the agreement. To cut a long story short, counsel for the respondent decided that he could not continue in the case because the Appellant was making allegations against him personally and he might have to appear as a witness, therefore he could not continue to conduct the case. He applied for an adjournment for new counsel to be instructed. The Appellant, rather than risk an adjournment and keen to get on with matters, withdrew his application for a stay, but counsel still pursued his application for an adjournment because he felt embarrassed to continue. The application was granted. It was clear that the Appellant, while withdrawing the application, was not withdrawing the allegations on which it was based.[22]When the matter was re-listed in August, the Appellant again sought to argue that there had been an abuse of process, but was refused leave to do so. The Panel considered the general nature of the application and ruled that, as it was similar if not identical to the two previous applications the Appellant had made, they would not hear or consider it. In my judgment, the Panel were perfectly entitled to take the view that, having withdrawn the application for a stay twice, they should not allow it to be made again. The Panel had spent a great deal of time dealing with preliminary matters which were then withdrawn and they were entitled, in order to dispose of the matter in a reasonable length of time, to refuse to hear more.[23]Having considered the witness statements, the transcripts and the submissions, I am satisfied that the admissions made by the Appellant were made of his own free will. While he no doubt was under pressure, the Panel were, and the respondent is, entitled to rely on those admissions. I am also satisfied that, after the admissions were made, the Appellant was given a reasonable opportunity to make representations about them.[24]As I have said, admissions as to certain of the charges were made by the Appellant at the beginning of day six, that is 12 August 2008. They can be found at pages 54 to 56 of the Appellant's bundle. They relate to incidents that took place at the Nevill Hall Hospital and the Cheltenham General Hospital. The Appellant also admitted that, having agreed to take a performance assessment, he changed his mind and did not do so. I have considered the detail of the charges and the statements on which they are based. The Appellant, in addition to making admissions, as I have said, agreed to withdraw his application for a stay. The Appellant also accepted that his fitness to practise was impaired. While it was stated on behalf of the respondent that the Appellant accepted impairment on the basis of the allegations that he accepted as well as the lapse of time since he had last practised, the transcript taken as a whole is ambiguous as to the basis on which he was accepting the impairment.[25]The respondent has pointed out that, in the light of the allegation, it was entitled to require the Appellant's performance to be assessed and that the Appellant has failed to comply without reasonable excuse. By Rule 17(8), that failure was something that the Panel were entitled to take into account in deciding whether or not the Appellant's fitness to practise was impaired. Counsel, when telling the Panel of the agreement, said the Appellant was eager to undergo an assessment of professional performance as quickly as possible, and the Appellant later confirmed his agreement with what counsel for the respondent said.[26]In the light of the admissions and the Appellant's failure to undertake the assessment, it was not surprising that the Panel found that the Appellant's fitness to practise was impaired. It gave detailed and cogent reasons for its decision. I am satisfied the Appellant was given a proper opportunity to address the Panel before they made that finding. At page 1884 of the transcript, the Appellant accepted that his fitness to practise was impaired because of the lapse of time since he last worked as a doctor.[27]The Appellant has submitted to me that it was not possible within the Rules to deal with the hearing in this way. He submits that, where undertakings are given, the case has to be withdrawn from the Panel. I am satisfied that his submissions as to that are completely misconceived. This is not a case where undertakings were made. What happened here is that admissions were made which shortened the fact finding exercise. After the admissions had been made there were no facts in dispute; that is different from a procedure which allows the respondent to take undertakings from a doctor and not proceed with the fitness to practise hearing in front of a Panel.[28]The panel then moved to the sanctions stage. The respondent submitted that the appropriate sanction was to attach conditions to the Appellant's registration, including a condition that he undertook a assessment of his professional performance. The Appellant supported that submission. The Panel, however, felt that it was inappropriate to make any sanctions until such time as it had seen the result of the assessment. They gave detailed and cogent reasons for that decision. The Appellant seeks to impugn that decision by submitting that the Panel had no power to adjourn for the purpose of seeking an assessment at that stage. His submission is that that power to ask for an assessment can only be exercised prior to the finding of impairment. Again, that submission is misconceived. While Rule 17(4) does provide a specific power to obtain an assessment prior to a finding of impairment, Rule 17(9) gives the power to adjourn before making a decision as to sanction for further information or reports. I see no reason to exclude from that power the right to ask for a performance assessment. It would be surprising if it did.[29]Although the Appellant had agreed to the assessment at the hearing, I am satisfied on the evidence that he changed his mind. He said initially that he was too ill to carry out the test but then applied for judicial review, largely on the basis of criticisms of the test which I have already summarised. He was refused permission on the papers. Pitchford J, in refusing permission, characterised the application as premature and indicated that he could convey his comments about the test to the Panel at the sanctions hearing. Pitchford J made his comments, clearly, in the belief that the Appellant would cooperate with the assessment and, if he believed it was unfair, explain that at the sanctions hearing.[30]The first part of the assessment involved a review of paperwork relating to the Appellant's practice. The location for that was chosen by the assessment team as the Nevill Hall Hospital. The Appellant complained at this choice as it was the hospital from which the complaints mainly emerged. It was, in my judgment, at the discretion of the assessment team where to carry out the first stage. It was, after all, the Appellant's longest locum post and would therefore have provided the largest number of records. The Appellant also complains that the assessment team were provided with the papers relating to the allegations. Again, where the aim of the assessment was to assist the Panel as to deficiencies in the Appellant's ability, it would seem sensible to do that within the context of the admissions that he had made.[31]Inevitably, because the Appellant did not take part in the assessment, it was incomplete. The Appellant made clear to the Panel his concerns about it and the Panel, in making its decision as to sanction, decided to give the report less weight than it would a full report. It also took into account the other concerns expressed by the Appellant. While the Panel took into account that the Appellant said that he was unable to meet some of the dates for the assessment because of ill health, it also concluded, correctly, that the reasons he did not take part went further than any question of ill health, namely his concerns as to the fairness of the process.[32]The Panel, in their reasons, were concerned at the continued failure of the Appellant to undertake the assessment and his continual changes of mind. It accepted that the complaints that had been proved were relatively minor, but there remained concerns that, because of the length of time since the Appellant had practised, it was impossible to decide the extent of his deficiencies. The Appellant's behaviour in repeatedly agreeing and then refusing to co-operate with the three GMC performance assessments indicated to the Panel a disregard by the Appellant of the respondent as a regulatory body. In an attempt to ensure that the Appellant did take the assessment, the panel considered that suspension was necessary. It also concluded that a review at the end of that period was necessary.[33]I am satisfied that the Panel had the power to make the orders that it did within the Rules. I am also satisfied that the sanction imposed was the correct one. The obligation on the respondent and on the Panel is to ensure the safety of the public. To do that in this case, it was essential that the Panel had a proper assessment of the Appellant's proficiency so as to identify areas of skill that needed to be addressed. The Appellant had demonstrated that to attempt to do that by adding conditions to his registration would not succeed. They were therefore correct, in my judgment, to consider and then impose suspension.[34]It is impossible to deal with everything that the Appellant has raised during the course of this hearing. In conducting this appeal, I have considered all of the arguments that he has presented orally and on paper. Having done that, I am satisfied that there was nothing procedurally improper in the course of the hearing, and I am also satisfied that the sanction imposed was the correct one. Accordingly, this appeal fails.[35]MS WHITE: My Lord, in the light of my Lord's judgment, the respondent applies for an order that the Appellant pay its costs of this appeal. I do have a schedule that has been provided in advance to Dr Uruakpa and I would ask my Lord summarily to assess those costs today.

MR JUSTICE SAUNDERS: I have not seen the assessment. (Document handed to the judge)

[37]MR JUSTICE SAUNDERS: I have seen that, thank you. Dr Uruakpa, the normal rule in this court is that the person who loses pays the costs of the other.[38]DR URUAKPA: Yes, my Lord.[39]MR JUSTICE SAUNDERS: Now, I am, of course, prepared to consider arguments from you as to why the normal rules should not apply. I am perfectly prepared to give you time to think about that and put any submissions that you may have in writing if you would find that easier to have time to consider my judgment and to think about what you want to say.[40]DR URUAKPA: Thank you very much for that, but what I have to say is just, I don't know if the statement you have is the one I have, my Lord, because I have one dated --

MR JUSTICE SAUNDERS: Has he got the same statement as me?

[42]MS WHITE: My Lord, I am not sure, my instructing solicitor emailed it to Dr Uruakpa yesterday.[43]MR JUSTICE SAUNDERS: Show it to Ms White and see if it the same document. You have not had it?[44]MS WHITE: My Lord, I apologise, I did see the email --[45]MR JUSTICE SAUNDERS: No, that is all right. We have also had some difficulty in communication by email with Dr Uruakpa, so, you are not the only one. I am concerned how to deal with this. I obviously want to deal with it properly, I want to give you time to consider it. It may be that your best idea would be to make submissions in writing which I will consider.[46]DR URUAKPA: My Lord, because of the stress associated with this case, I would be pleased if I can have some conclusion today, my Lord. I have a document sent to me by the respondent on 22 April.[47]MR JUSTICE SAUNDERS: You had better have a look at the document which has actually been sent to you --[48]MS WHITE: If I might explain, my Lord, a letter was sent with an interim statement before I was instructed and, therefore, my Lord, is considerably different to the final.

MR JUSTICE SAUNDERS: Well, the total costs asked for are £30,649?

[50]MS WHITE: My Lord, yes.[51]DR URUAKPA: What I have here is for £12,732, my Lord. My understanding is that, I don't know if I am wrong, my Lord, is that any application for costs should be made before the hearing, or at least on the day of the hearing. I don't know that is according to the White Book, my Lord, and I received this before the hearing. My view is that, if that is the case that we should consider the one that I received before the hearing which is the costs for £12,000, my Lord.[52]MS WHITE: My Lord does have that. My Lord also has the letter under cover of which that was sent.

MR JUSTICE SAUNDERS: Those are costs to 31 March 2010?

[54]DR URUAKPA: Yes, my Lord.[55]MS WHITE: My Lord, yes, which effectively do not conclude counsel's costs for the skeleton and hearing.[56]MR JUSTICE SAUNDERS: I am happy to look at them in detail and see whether I think they are reasonable sums.[57]DR URUAKPA: What I have to say, my Lord, is that, even the costs for £12,000 I believe is excessive and disproportionate. I am a litigant in person who has little legal grounding and it was left for the respondents to send somebody who was a solicitor would have been appropriate for this case, but if the respondents now went ahead and obtained the services of counsel at much greater expense, then I wish that my Lord would take that into account. I also plead with my Lord to take into account the fact that I have been unemployed for the past 5 years, I have not been able to earn any income in the past 5 years, and that this appeal has been an attempt to ensure that I have the best chance of getting back into employment.[58]MR JUSTICE SAUNDERS: Okay. If you do not mind me saying so, your best chance of getting back into employment is to take the proficiency test, and that has been the situation for a very long time. It is one of the tragedies of this case that you have not been prepared to do that, but I am not here to advise you.[59]DR URUAKPA: I would be very grateful if my Lord can dispose of this case today and the expenses of £12,000 would not help me, it would destroy me financially, mentally, intellectually, and it would not even allow me to take the proficiency test, my Lord. If there is any hope of my ever taking that test, the excessive bill of the respondents are attempting to clamp down on me would extinguish any chances or hopes that I have of attempting the proficiency test, my Lord. So I plead with my Lord to be compassionate --[60]MR JUSTICE SAUNDERS: Well, it is not really a matter of me being compassionate. I am obviously very sorry for the situation you find yourself in, I feel it very unfortunate and, as I said, I think it is, to an extent, a tragedy that this has happened. OK, anything else you want to say?[61]DR URUAKPA: That is all, my Lord.

MR JUSTICE SAUNDERS: OK, thank you.

[63]Ms White, both Beatson J and Collins J have indicated that there was excessive delay or inexcusable delay by the respondents at the stage that they came to consider the matter, and extending matters. Undoubtedly, the fact it has gone on so long has, of itself, meant it has been very difficult for Dr Uruakpa to actually practise. It may be that he was never going to take the test anyway, in which case it made absolutely no difference. Is that not a basis on which I can justifiably reduce the amount of costs which I order him to pay?[64]MS WHITE: My Lord, I am in some difficulty as I was not involved in those earlier hearings that were quite some time ago --[65]MR JUSTICE SAUNDERS: But they are findings by judges who were addressed on behalf of the GMC as well.[66]MS WHITE: My Lord, yes. I would have expected that the judge's findings would have been reflected in the orders for costs that they made at the relevant time. I am afraid I do not ave them in front of me and I do not know what the costs were, but, my Lord, in my submission, my Lord should be concerned, when looking at the conduct of the parties, with the conduct of the parties on this appeal to this court and, therefore, what my Lord should consider is whether the respondent has acted reasonably and proportionately in incurring the costs that it did in defending itself against the enormous number of arguments advanced by Dr Uruakpa.[67]MR JUSTICE SAUNDERS: I understand that, but are you saying I am not entitled it take into account the fact that, at an early stage of these proceedings, the court has found twice that there have been unjustified delay by the GMC?[68]MS WHITE: My Lord, I do say that, for the reasons that I outlined to my Lord earlier. In my submission, those are quite different proceedings to the proceedings before my Lord.

MR JUSTICE SAUNDERS: OK, thank you.

[70]MS WHITE: My Lord is of course entitled to look at the costs and assess them.[71]MR JUSTICE SAUNDERS: Yes. Obviously whether you can ever get the money out of Dr Uruakpa is another matter.[72]MS WHITE: Yes, absolutely, my Lord.

MR JUSTICE SAUNDERS: OK, thank you.

[74]Doctor I will make an order for costs. It will be more than £12,732. I am going to look at the detail of this and see whether they can be reduced down from the figure that there is on the basis of some of the things I have said. It will be more than that, the minimum it will be will be in the region of £20,000. I am going to look at it to see what should be the appropriate figure, I am not going to give you an answer today. When you get the judgment, the perfected judgment, that will include all my order, which will include the amount of the costs. Do you understand?[75]DR URUAKPA: Yes, my Lord.[76]MR JUSTICE SAUNDERS: I am sorry it is not finished today but it is not in your interests for me to not have an opportunity to think about it. Ms White, would you assist the Court by drawing up the appropriate order?[77]MS WHITE: Yes, my Lord.[78]MR JUSTICE SAUNDERS: I will put in the amount for the costs. There will be an order for costs, the amount I will fill in. Would you also be good enough to check the judgment which, as I said, will still have to be perfected, but if I give you what I have read out, if there are any inaccuracies I would be grateful to be reminded of them.[79]MS WHITE: Certainly, my Lord. Is there any particular date by which my Lord would appreciate this? I anticipate being able to do it in the course of tomorrow, my Lord, but --[80]MR JUSTICE SAUNDERS: Well, 7 days will be enough. You will get the perfected judgment in about 14 days, which will include the amount of costs.[81]Thank you very much.[82]Having further considered the application for costs, in my judgment the appropriate and fair figure is £22,500. That is to reflect some reduction in the amount claimed and some reduction to reflect the delay found by Beatson and Collins JJ. to have been the fault of the Respondent. It is at least a possibility that that delay has led to the Appellant being unable to earn a living for a longer period than it otherwise would have been.