Karl Hough v Health and Care Professions Tribunal Service [2026] EWHC 743 (Admin)

[2026] EWHC 743 (Admin)Case No AC-2025-MAN-000485
IN THE HIGH COURT OF JUSTICE
KING’S BENCH DIVISION
ADMINISTRATIVE COURT
Venue SITTING IN MANCHESTER, Manchester Civil Justice Centre, 1 Bridge Street West Manchester M60 9DJDate 27/03/2026
Before
MRS JUSTICE HILL DBE:
Between
KARL HOUGHClaimantHEALTH AND CARE PROFESSIONSDefendantTRIBUNAL SERVICEDefendant
Ani Yeghikian (instructed by Blackfords LLP) for ClaimantMatthew Cassells (instructed by Blake Morgan LLP) for DefendantHearing Hearing date: 19 March 2026
JUDGMENTApproved JudgmentThis judgment was handed down remotely at 10.30am on Friday 27 March 2026 by circulation to the parties or their representatives by e-mail and by release to the National Archives.............................

Introduction

[1]This is an appeal under Article 29(9) of the Health Professions Order 2001 (SI 2002/254) (“the 2001 order”). The Appellant appeals against a decision of a Panel of the Conduct and Competence Committee (“the Panel”) of the Health and Care Professions Council (“the HCPC”) dated 28 March 2025. The Panel found that his fitness to practise was impaired by reason of misconduct and the Registrar was directed to strike his name from the register. The Appellant appeals the findings of fact, the findings with respect to misconduct and impairment and the sanction.

The factual background

[2]The Appellant has been a registered Paramedic for some 30 years. In 1989, he began working for North West Ambulance Service NHS Trust (“NWAS”). By 2018 he was working as an Advanced Paramedic.[3]On 16 May 2018 and 30 July 2020 the HCPC received referrals about the Appellant relating to two separate incidents.[4]The first had taken place on 14 March 2018. It involved Patient A, a child with a rare neurological condition. The person referred to as Witness 1 before the Panel was a Highly Specialised Community Respiratory Physiotherapist in the Community Physiotherapy Service of Alder Hey Children’s Hospital (“the Hospital”).[5]On 14 March 2018, Patient A’s oxygen saturation levels had been lower than normal overnight and he was experiencing more secretions than usual. This was not an acute concern and Patient A went to school as normal. Patient A’s mother reported the lower oxygen saturation levels to Witness 1. Witness 1 attended the school. The school staff reported that they were also concerned about Patient A’s oxygen saturation levels. Witness 1 assessed these and decided that Patient A’s presenting condition meant that the Emergency Treatment Plan, which she and Patient A’s Respiratory Consultant at the Hospital had drafted, should be followed.[6]Having begun treatment under this plan, Witness 1 remained concerned and asked staff at the school to make a 999 call. An ambulance arrived shortly after with two paramedics (Witness 2 and “GB”). Despite some improvement in Patient A’s presenting condition, it was decided it would be desirable for him to be transferred to the Hospital. Witness 1 offered to travel with Patient A to the Hospital to assist with ventilation and suction. This offer was accepted.[7]The Appellant then arrived with two other people (Witness 3, a paramedic, and “MH”). Thereafter it was alleged, in summary, that the Appellant failed properly to communicate or engage with Witness 1; and that he made errors in terms of proper infection prevention control and record-keeping/communication with other medical teams during the incident.[8]The second incident had taken place on 11 July 2020. It involved Patient D, an adult who had suffered a cardiac arrest in his home. Patient D was initially attended by two Community First Responders who achieved return of spontaneous circulation. Witnesses 5 and 6, two newly qualified paramedics attended and confirmed the presence of a palpable carotid pulse and return of spontaneous circulation. Patient D’s oxygen saturation levels remained low and ventilation was assisted with a bag valve mask. A 12-lead ECG confirmed Patient D had suffered a myocardial infarction.[9]A second ambulance crew arrived and assisted with transferring Patient D to the first crew’s ambulance. The second ambulance crew left and the first crew awaited the arrival of the Appellant. The Appellant attended, accompanied by a senior paramedic (Witness 8). Thereafter it was alleged, in summary, that the Appellant inappropriately administered and/or directed to be administered medications to the patient; made a clinical error in respect of Patient D’s oxygen mask; and made false or inaccurate records in relation to Patient D. Proceedings before the Panel The evidence

Proceedings before the Panel

[10]The Panel heard evidence over 10-11, 13-14 and 17-21 March 2025. The HCPC called seven witnesses. They also relied on one hearsay witness statement from “CG” and part of an expert report prepared by Dr Timothy Kilner, Principal Lecturer in Paramedic Sciences and Head of Department at the University of Wolverhampton. The Appellant gave evidence on his own behalf. The Panel considered an extensive bundle of documents.[11]At the end of the evidence the Panel received advice from their legal assessor as to the approach to be taken to the process of finding the facts. The representative for the HCPC, Mr Irving, and the Appellant’s counsel, Ms Yeghikian, provided the Panel with detailed written submissions on the facts. It was later agreed that no oral submissions were required.

The Panel’s findings of fact

[12]On 25 March 2025 the Panel found the following charges against the Appellant proved in respect of the first incident: “1. On 14 March 2018, whilst attending an incident involving Patient A, you:a. Ignored the advice of Witness 1, who was the primary care giver.b. Refused to allow Witness 1 to travel with Patient A in the ambulance.c. …d. Did not complete the patient records to an acceptable standard in that you incorrectly recorded Patient A’s oxygen saturation and/or you did not record the consultation or assessment model followed.e. Displayed unprofessional communication towards Witness 1 and colleagues on scene.f. Did not demonstrate infection prevention control awareness in that you did not change your gloves between touching equipment and treating…Patient A”.[13]On the same day, the Panel found the following charges against the Appellant proved in respect of the second incident: “2. On 11 July 2020 you administered a bolus of 10 mg morphine to Patient D:a. to sedate Patient D contrary to Joint Royal Colleges Ambulance Liaison Panel guidelines and/or safe clinical practice; and/orb. which was an excessive dosage for pain relief; and/orc. without having conducted an adequate risk assessment. 3. On 11 July 2020 whilst attending an incident involving Patient D contrary to Joint Royal Colleges Ambulance Liaison Panel guidelines and/or NWAST Patient Group Direction, you: a. Directed Colleague 1 to administer 3 doses of 2.5mg midazolam to Patient D, when Colleague 1 was not authorised to administer midazolam under NWAST Patient Group Direction. b. Directed Colleague 1 to administer 3 doses of 2.5mg midazolam to Patient D when it was not clinically indicated. c. Directed Colleague 1 to administer 3 doses of 2.5mg midazolam to Patient D, which is a higher dose than that indicated by the NWAST Patient Group Direction for high risk adults. 4. On 11 July 2020 you did not ensure that an oxygen supply tube was connected to the bag valve mask whilst ventilating Patient D and/or recognise a prolonged period of hypoxia in Patientd. D. 5. On 11 July 2020 you did not keep adequate and/or accurate records in relation to Patient D in that you: a. Did not record a complete history; and/or b. Did not record accurate observations; and/or c. Recorded yourself as having administered midazolam when this was not the case. 6. Your conduct in respect of Particular 5 (c) was dishonest”.[14]At the outset of the hearing, the Appellant had made admissions to the charges at 1(b), 1(f), 2(a), 2(b), 3(a), 3(c), 4 and 5(c). The others were found proven based on the evidence before the Panel.[15]The Panel did not find proven one further charge at paragraph 1(c), to the effect that during the first incident the Appellant had “[p]rovided inconsistent information to Emergency Operations Centre (EOC), regarding the patient’s condition and/or observations”.[16]The Panel set out their reasons with respect to the findings of fact in their written Decision at [12]-[90].[17]Having given their decision on the facts, the Panel received oral submissions from the representatives and legal advice on the issue of misconduct.

The Panel’s findings on misconduct

[18]On 27 March 2025, the Panel decided that the particulars proven against the Appellant amounted to misconduct.[19]The Panel set out their reasons with respect to the decision of misconduct in their Decision at [91]-[98].[20]The Panel concluded that the findings of fact demonstrated that the Appellant had acted in a way that was contrary to nine different aspects of the Standards of Proficiency for Paramedics. Further, they found that this was not a case in which the Appellant was not able to perform differently: rather this was a case in which the Appellant had chosen not to perform in a manner that he was able to: [95]-[97].[21]The Panel recognised that some of the factual findings taken in isolation would be more serious than others. However, they continued: “A finding that a professional person has acted dishonestly is a very serious matter for reasons too obvious to require elaboration. The administrations of inappropriate medication and excessive quantities of medication to an acutely unwell patient were also particularly serious matters. When the panel considered whether it would be appropriate to exclude from a finding of misconduct any element of the established facts, it concluded that it would not. This is because each part of the findings in relation to each patient represented part of the overall management of the patient performed by the [Appellant], and those managements were of the utmost serious and would be regarded as deplorable”: [97].

The Panel’s findings on impairment

[22]The Appellant gave further evidence to the Panel addressed to the issue of impairment. He was no longer working for NWAS. He said that since January 2021 he had been working under interim conditions of practice, delivering Covid-19 vaccine injections and working with patients with a high level of clinical need. He said that these roles had enabled him to develop techniques of active listening, empathy and negotiation. He provided a bundle of testimonials which supplemented those he had previously provided.[23]The legal representatives made submissions on the issue of impairment. Ms Yeghikian argued on the Appellant’s behalf that the Panel was dealing with an isolated incident in relation to which there was no risk of repetition. The Panel received legal advice on the issue.[24]The Panel then decided that the Appellant’s fitness to practice was impaired, setting out their reasons for doing so in their Decision at [100]-[115].[25]As the HCPC’s Practice Note had directed the Panel, the impairment issue in this context involves “personal” and “public” components.[26]As to the personal component, the Panel observed that both Patient A and Patient D were acutely unwell patients. The circumstances of each of their cases were complex and “obviously so”. The Panel observed that any paramedic, even one who had not been qualified as long as the Appellant or working at his senior level, would know that when there is a complex case involving an acutely unwell patient it is a paramount importance to follow best clinical practice including established guidelines. Further, if those requirements are departed from, there must be a very good reason for doing so and those reasons would require careful and detailed explanation. However, the Panel found that: “…in each case the [Appellant] departed from the manner in which he unquestionably understood he should have acted, and he did so when there was insufficient rationale to do so, and did not explain why he acted”: [106].[27]The Panel went on to consider why the Appellant had acted as he did, in order to assess whether there remained a risk that he was likely to act in a similar manner in the future. The Panel concluded that: “…the underlying reason for both incidents was the same, namely the [Appellant] pursing his own course of action whilst ignoring established requirements: [108].[28]The Panel noted that the Appellant had been made subject a two-year warning (imposed by his employer) in respect of his conduct towards Patient A. They made clear that they paid no heed to the Appellant’s employer’s view of the seriousness of the incident (that being for them to determine in the context of fitness to practise). However, they noted that “[i]t might have been expected that that warning would have served to make [the Appellant] mindful about the way he practised”: [108].[29]The Panel observed that at the “root” of the problem in this case was an “attitudinal shortcoming” on the part of the Appellant. The Panel observed that conceptually, even if a shortcoming is attitudinal in nature, it is capable of remediation in the sense that, with a change in attitude, it might not be repeated. The Panel identified that the “all-important question” for them to determine was whether there was material before them from which it could conclude that the Appellant would not repeat this type of behaviour: [109].[30]The Panel gave careful consideration to the Appellant’s evidence about his professional activities since leaving his employment with NWAS. The Panel noted that in the work he had done under the interim conditions of practice, there was no suggestion that any further untoward incidents had occurred. The Panel had careful regard to both sets of testimonials provided by the Appellant. They observed that they “did not doubt” that the Appellant had the knowledge and skills to practise safely and effectively; nor that on the whole he had in the past, and continued to, practise safely and effectively. However, the issue that concerned the Panel was “whether the [Appellant] can be relied upon consistently to practise safely and in a manner he undoubtedly knows he should”: [110].[31]The Panel concluded that the Appellant’s testimonial evidence was of limited value in answering this question because the extremely serious incident concerning Patient D occurred after all of the documents had been written: [110].[32]The Panel noted that the Appellant had admitted some of the charges found proven, but considered that:
“…the case he had advanced does not suggest that he has, even now, after all the time that has passed since the incidents occurred, a true understanding of just how inappropriate his actions were”
. His evidence “did not involve a real understanding of how serious his behaviour was, and, importantly, did not actually accept any wrongdoing”: [111].[33]They continued: “To be clear, the [Appellant] is entitled to advance and stand by any case he chooses. But at the same time it must be understood that the panel is entitled to decide the case on the basis of that case. Furthermore, when a hearing lasts as long as the present one, the Panel conducting it is very likely to be able to form a view of the demeanour of those involved. The Panel’s assessment of the Appellant is one that is consistent with what it has described as the fundamental reason these incidents occurred”: [112].[34]Overall, the Panel concluded that there remained a “significant risk that the [Appellant’s] character is such that he would in the future choose to act outside clinical standards and professional expectations”: [113]. Accordingly, the Appellant’s fitness to practise was impaired on the personal component.[35]On the public component, the Panel found that the Appellant’s fitness to practise was impaired in view of the seriousness of the Appellant’s conduct, irrespective of their finding as to the risk of repetition, for these reasons: “Were there to be no finding of current impairment of fitness to practise in these circumstances, fair-minded and informed members of the public would not have the confidence they can reasonably expect to have in the Paramedic profession or the regulation of it. Furthermore, without a finding of current impairment of fitness to practise, the Panel would be failing to discharge its duty to establish for other professionals the proper bounds of acceptable professional practice”: [114].

The Panel’s findings on sanction

[36]The Panel then received submissions and legal advice on sanction. After Ms Yeghikian had concluded her submissions, the Appellant addressed the Panel himself.[37]On 28 March 2025, the Panel imposed a striking off order, for the reasons given in their Decision at [116]-[136].[38]The Panel considered the HCPC’s Sanctions Policy (March 2019).[39]The Panel began its consideration by seeking to identify any facts that were serious and aggravating and those that it would be proper to take into account on behalf of the Appellant: [121].[40]As to the first of these issues, the Panel concluded as follows: “A serious aspect of this case is that, contrary to the submission made on behalf of the [Appellant], the Panel is dealing with two incidents. Two distinct incidents occurred, and there were features of both arising from the failure to work in partnership that were common to both, shortcomings that resulted in the [Appellant] failing to provide the example of leadership his senior position required him to demonstrate. The second incident occurred when, as the Panel has already stated, it might have been expected the [Appellant] would have been mindful to ensure that he observed proper standards”: [122].[41]The Panel continued: “Another serious aspect of the case is that an aspect of the latter incident involved dishonesty. The Panel accepts that it was a single incident of dishonesty, rather than a repeated pattern of dishonest behaviour, but it was nevertheless serious because it involved an attempt to cover up the improper administration of a controlled drug”: [122].[42]Finally, the Panel turned to the risk of harm, finding as follows: “…both of these patients were very vulnerable and they were acutely unwell. The risks the [Appellant] needlessly exposed them to when neither fanciful nor remote. The [Appellant’s] incomplete insight into how he acted, coupled with his reluctance to acknowledge wrong-doing and tendency to shift blame has led the Panel to conclude that he presents a significant risk of repeating behaviour of the type he demonstrated when dealing with Patient A and Patient D. Were he to repeat that behaviour, the patient being attended would be exposed to the same degree of risk Patient A and Patient D were exposed to”: [122].[43]On behalf of the Appellant, the Panel considered that the following matters could properly be taken into account: “The Panel accepted that the [Appellant] self-referred to the HCPC in respect of the two incidents that have been considered by the panel. It was also accepted that he was fully engaged in this fitness to practise process and admitted some aspects in relation to each incident while offering a limited apology. The Panel acknowledged that the [Appellant] has undertaken some, albeit limited, reflection and recognise the need for some behavioural change on his part. The Panel further acknowledged that it has not been suggested that there have been further problems with the [Appellant’s] practise in the period of a little over four years since he was dismissed by NWAS and has been undertaking alternative work under interim conditions of practice”: [122].[44]The Panel determined that whilst a suspension order would protect the public it would serve no other purpose. Having reached that conclusion, the Panel considered whether a striking off order was appropriate and proportionate and considered it was. Their detailed reasons for these decisions are set out at [119] and [122] below.[45]At the conclusion of the hearing, the Panel imposed an interim order suspending the Appellant from practice, pending his appeal.

The legal framework in outline

[46]The principal functions of the HCPC are to establish and ensure the maintenance of standards in respect of education, training, conduct and performance for its members. Its overarching objective is the protection of the public: see Articles 3 and 5 of the 2001 order.[47]Appeals against orders made by a Conduct and Competence Committee under Article 29(9) of the 2001 order are governed by Article 38 thereof and CPR 52.[48]Under Article 38(3) the Court may dismiss the appeal, allow the appeal and quash the relevant decision, substitute for the relevant decision any other decision which could have been made or remit the case back to the relevant Panel with directions.[49]Under CPR 52.21(3), the appeal court will allow an appeal where the decision of the lower court was(a) “wrong”; or(b) “unjust because of a serious procedural or other irregularity” in the proceedings in the lower court[50]In Hawker v Health and Care Professions Council [2022] EWHC 1228 (Admin) at [33], Eyre J summarised the approach of the Court to appeals of this kind, which has been established in a series of authorities, thus: “The test I have to apply is whether the Decision was wrong. I am not bound by the conclusions reached by the Panel and must consider also whether the sanction imposed was appropriate and necessary or excessive and disproportionate. However, I must have in mind the weight to be attached to the specialist knowledge of the members of the Panel as to the standards to be expected of registered paramedics; the relative gravity of the misconduct in question; and the level of sanction necessary to maintain public confidence in the profession. In addition, I must remember the benefit which the Panel had of seeing and hearing the evidence of the Appellant and the other witnesses. I derive those propositions from the decisions of the Privy Council in Ghosh v General Medical Council [2001] UKPC 29, [2001] 1 WLR 1915; of the Court of Appeal in The Professional Standards Authority v The Health & Care Professions Council (Doree) [2017] EWCA Civ 319; and of the Court of Appeal in Bawa-Garba v General Medical Council [2018] EWCA Civ 1879”.[51]Although the decision of a professional regulator “deserves respect” (see, for example, Doree at [5]), it should not be slavishly followed “more than is warranted by the circumstances”: Ghosh at [34].[52]There is a duty on a professional tribunal to give reasons for its decisions. I summarised the extent of that duty in Shabir v General Medical Council [2023] EWHC 1772 (Admin) as follows: “18…(i) The purpose of a duty to give reasons is to enable the losing party to know why they have lost and to allow them to consider whether to appeal: English v Emery Reimbold & Strick [2002] 1 WLR 2409 at [16] and Byrne at [24]. (ii) It will be satisfied if, having regard to the issues and the nature and content of the evidence, reasons for the decision are apparent, either because they are set out in terms or because they can readily be inferred from the overall form and content of the decision: English at [26] and Byrne at [24]; (iii) There is no duty on a tribunal, in giving reasons, to deal with every argument made in submissions:English at [17]-[18]; (iv) In a straightforward case, setting out the facts to be proved and finding them proved or not will generally be sufficient both to demonstrate to the parties why they have won or lost and to explain to any appellate tribunal the facts found: Southall [v General Medical Council [2010] 2 FLR 1550] at [56] and Gupta[v GMC [2002] 1 WLR 1691] at [13]; (v) Where the case is not straightforward and can properly be described as “exceptional”, the position will be different: a few sentences dealing with “salient issues” may be essential: Southall at [56]; (vi) Specific reasons for disbelieving a practitioner are not required in every case that is not straightforward: Byrne at [119]; and (vii) Where a Tribunal’s stated reasons are not clear, the court should look at the underlying materials to seek to understand its reasoning and to identify reasons which cogently justify the decision. An appeal should not be allowed on grounds of inadequacy of reasons unless, even with the benefit of knowledge of the evidence and submissions made below, it is not possible for the appeal court to understand why the tribunal reach the decision it did: English at [89] and [118] Byrne at [27].[53]On appeal, a realistic and reasonably benevolent approach should be taken, such that decisions are read fairly and not hyper-critically, see, for example, DPP v Greenberg [2021] EWCA Civ 672 at [57]. Ground 1: The Panel’s findings of fact Relevant legal principles

Ground 1: The Panel’s findings of fact

[54]In Byrne v General Medical Council [2021] EWHC 2237 (Admin), Morris J reviewed a series of authorities addressing the approach of an appellate court to a finding of fact, and in particular a finding of primary fact, by the court below. He distilled a number of propositions as follows: “12. First, the degree of deference shown to the court below will differ depending on the nature of the issue below; namely whether the issue is one of primary fact, of secondary fact, or rather an evaluative judgment of many factors…13. Secondly, the…starting point is that the appeal court will be very slow to interfere with findings of primary fact of the court below. The reasons for this are that the court below has had the advantage of having seen and heard the witnesses, and more generally has total familiarity with the evidence in the case. A further reason for this approach is the trial judge’s more general expertise in making determinations of fact…14. Thirdly, in exceptional circumstances, the appeal court will interfere with findings of primary fact below…15. Fourthly, the circumstances in which the appeal court will interfere with primary findings of fact have been formulated in a number of different ways, as follows: - where “any advantage enjoyed by the trial judge by reason of having seen and heard the witnesses could not be sufficient to explain or justify the trial judge’s conclusions”: per Lord Thankerton in Thomas v Thomas [[1947] AC 484] approved in Gupta; - findings “sufficiently out of the tune with the evidence to indicate with reasonable certainty that the evidence had been misread ”; per Lord Hailsham in Libman [v General Medical Council [1972] AC 217]; - findings “plainly wrong or so out of tune with the evidence properly read as to be unreasonable”: per Casey [v General Medical Council [2011] NIQB 95] at §6 and Warby J (as he then was) in [R (on the application of Dutta) v General Medical Council [2020] EWHC 1974 (Admin)] at §21(7); - where there is “no evidence to support a…finding of fact or the trial judge’s finding was one which no reasonable judge could have reached”: per Lord Briggs in Perry [v Raleys Solicitors [2019] UKSC 5] after analysis of McGraddie [v McGraddie [2013] UKSC 58];and Henderson [v Foxworth [2014] UKSC 41]. In my judgment, the distinction between these last two formulations is a fine one”.[55]Ritchie J returned to this theme in Evboren v Nursing and Midwifery Council [2024] EWHC 2975 (Admin), holding as follows:
“31…If a finding of fact of the Panel is irrational or such that no reasonable Panel could have made it, that will fall comfortably within the definition of “wrong”
. Likewise, if the finding was made taking into account irrelevant matters or omitting from account relevant material and matters, that falls comfortably within the definition of “wrong”. If a finding is based on no evidence at all, that will fall within the definition of wrong. 32. When the appellate Court is dealing with findings which are alleged to be: (1) “against the weight of the evidence”, or (2) an incorrect assessment of credibility, or (3) made by ignoring some identified contrary evidence, the test for what is wrong is more difficult to define, however, there are three “deference” thresholds which the appellate courts have identified to assist before a finding can be determined as wrong”.[56]First, Ritchie J referred to the “due deference to professionals” threshold, describing this as follows: “33…there is a principle that deference should be shown to the expertise and experience of a professional Panel in professional regulatory appeals. This threshold is raised or lowered depending on the nature of the issue to which the finding of fact or decision related and the composition of the panel. If it related to clinical matters the threshold may be raised. If it related to mere fact finding (did this sexual act occur or not) it may be lowered. Thus, this threshold is described as being one where “the appropriate degree of deference” is given to the Panel. One factor to take into account is the composition of the Panel, for instance are they or are they not practitioners within the relevant field?”.[57]Second, he described the threshold of “live evidence deference”, in this way: “34…deference is due to the tribunal who heard the live evidence…This threshold espouses the obvious advantage that the first instance tribunal has when assessing the evidence because they will have heard all of the witnesses and seen them and so heard evidence in-chief, cross-examination and re-examination, often over many days…This advantage has been described as the tribunal having the whole “sea” of the evidence whereas the appellate Court only has “island hopping” evidence. Overall, appellate Courts have stated many times that they will not interfere unless satisfied that the advantage enjoyed by the first instance tribunal could not be sufficient to explain or justify the conclusion reached. This threshold is tempered a little by the acknowledgment in rulings that mere demeanour is not a powerful determinant of credibility (see Andrews J. at para 59 in Suddock v NMC [2015] EWHC 3612)”.[58]Third, Ritchie J referred to the threshold of “deference due to the generous ambit of disagreement”, in this way:
“35. The third threshold is deference due to the “generous ambit of disagreement” principle….Under this threshold appellate Courts are obliged to take into account that there is a generous ambit of disagreement allowed to the first instance tribunal on a decision of fact before the appellate Court will declare a decision wrong”
.

Submissions and analysis

[59]The Appellant advanced an overall contention that the Panel’s decisions in respect of the facts were not well-founded and there was no proper consideration of the weight of the evidence presented.[60]First, Ms Yeghikian submitted that the Panel’s decision that the facts were proved against the Appellant was wrong in that the Panel failed to have regard to the numerous inconsistencies in the evidence of the HCPC’s witnesses. These inconsistencies were, she argued, central to the Panel’s assessment of the credibility of the witnesses; such that they should have been highlighted and recognised by the Panel.[61]I cannot accept this submission. I was taken to no particular section of the closing submissions on the facts which set out the alleged inconsistencies relied on for the purposes of this argument. However, the Panel gave careful consideration to their assessment of the credibility of the evidence of the HCPC witnesses in respect of the first incident, as follows: “21. Before explaining its decisions on the relevant factual particulars, it is appropriate for the Panel to explain its findings about the reliability of the evidence it received from those who were present that day. In relation to this incident, the HCPC called Mrs MM, Mr RJ and Mr AS. Neither Mr GB nor Mr MH was called as a witness by either the HCPC or the [Appellant]. As already stated, the [Appellant] gave evidence in his own defence.22. In assessing whether a consistent picture was painted by the individuals who gave evidence about the events of 14 March 2018, it was important for the Panel to remember that the incident was one concerning an acutely ill child. This factor was important not only for a fair assessment of how people should have been expected to behave, but also relevant in deciding if their recollections after the event were reliable, not least because at the time they would have been focused on Patient A. However, so far as the three witnesses called by the HCPC were concerned, Mrs MM, Mr RJ and Mr AS, the Panel was satisfied strove to describe events as they genuinely remembered them. Each of them made a statement nearer the time. In the case of Mrs MM, she wrote an account which she submitted to the Hospital very shortly after the incident. She was interviewed by the NWAS investigator, Mr JC, on 20 June 2018, and a summary of that interview was provided to the Panel. Mr RJ made a statement dated 12 May 2018 in the context of the NWAS investigation and a witness statement for these proceedings dated 15 May 2021. Mr AS made a witness statement for these proceedings on 2 June 2021. In the judgement of the Panel, when due allowance was allowed for the fact that they were describing events that occurred seven years earlier, the oral evidence of each of these witnesses to the Panel was consistent with their earlier written accounts. Furthermore, the Panel did not detect any sign that any of them had chosen to exaggerate the criticisms they made of the [Appellant]’s behaviour.23. The HCPC also called as a witness Mr JC, at the time a recently appointed Consultant Paramedic. Mr JC conducted the NWAS investigation into the incident. Given his role, Mr JC was not able to give direct evidence about what or did not happen during the incident. He was able, however, to give evidence about his investigation, and the Panel accepted his evidence in this regard, including his evidence that the summaries of the interviews in which he participated were fair summaries of what was actually said by those interviewed”.[62]Accordingly, it is clear that the Panel took into account the context of the incident in question (one concerning an acutely ill child); the fact that each of the three HCPC witnesses to the incident (Mrs MM, Mr RJ and Mr AS) had given an account shortly after it; their impression that each of the witnesses was trying to describe events as they genuinely remembered them; the fact that their accounts were consistent with their earlier written accounts; and the fact that the Panel did not detect any sign that any of them had chosen to exaggerate the criticisms they made of the Appellant’s behaviour. This was a paradigm example of a Panel assessing the witness evidence before it in a fair and measured way.[63]The Panel also carefully assessed any alleged inconsistencies in the HCPC evicence in respect of the second incident, in this way: “53. Before addressing the specific factual particulars alleged in relation to Patient D, the Panel assessed the reliability of the evidence of the witnesses who gave evidence about the matter. Both Ms CP-J and Mr BB gave evidence before the Panel. Each submitted a DATIX concerning the incident very shortly after the incident, and they were both interviewed in the context of the NWAS investigation into the matter, the written summaries of what was said by them being provided to the Panel. Furthermore, each of them made a witness statement in September 2021 for the purposes of the present proceedings. Having given due allowance for the fact that different people will inevitably remember a given event differently, as well as to the fact that the incident occurred nearly five years ago, the Panel found that their evidence was consistent with the earlier accounts they had given. The Panel was satisfied that the evidence of them could safely be relied upon in deciding the relevant factual particulars.54. The HCPC also called as a witness, Mr NS, a Consultant Paramedic. Mr NS’s role was that of investigator for the purposes of the NWAS investigation. As such he did not have any personal knowledge of the events of the incident on 11 July 2020, but the Panel accepted his evidence that the documents he produced were accurate in the sense that they were what they purported to be, and that records of interviews he had attended accurately reflected what was said in those interviews.55. The HCPC also relied upon the hearsay statement of Ms CG, permission for the use of it having been given by another panel at an earlier Preliminary Hearing”.[64]Again, the Panel considered the context of the incident which Ms CP-J and Mr BB were describing and the fact that they had each submitted a DATIX report very shortly after the incident. They made “due allowance” for the fact that different people will inevitably remember a particular event differently, and the lapse in time since the incident, but still found that the witnesses’ evidence was consistent with the earlier accounts they had given, such that it could be relied upon. Again, I can see no basis for criticising the Panel’s approach to the alleged inconsistencies in the witness evidence about the second incident,[65]Indeed, as Mr Cassells highlighted, it was the Appellant’s evidence which the Panel concluded showed unhelpful inconsistencies: “24. It has already been stated that the [Appellant] gave evidence in his own defence. The Panel found him to be an unconvincing witness for three distinct reasons. 25. The first aspect of the [Appellant]’s evidence the Panel found to be unsatisfactory was that when asked questions about his own actions, he had a tendency to answer by referring to what other witnesses had said or written in their accounts. This was very unhelpful when the point of the question was to discover what his own account was, and in reality, amounted to an argument or submission rather than evidence. 26. The second aspect of the [Appellant]’s evidence was that he had a tendency to reply by reference to the motivations or qualifications of people who gave evidence that conflicted with his own case. The Panel found that his was a highly personalised approach to giving evidence.Indeed, on occasions it appeared that he believed that people had decided to work against him. An example of this was provided when he described the other NWAS staff present at the school on 14 March 2018 being “complicit” with Mrs MM. 27. Third, there were significant respects in which the [Appellant]’s oral evidence to the Panel was quite simply inconsistent with earlier accounts he had given. There were examples of this both in relation to Patient A and Patient D. For example:• In his oral evidence, the [Appellant] stated that Mrs MM was forcibly holding Patient A down, and that accordingly, he thought she presented a risk to the child. He did not mention this in his responses in the NWAS investigation.• In his oral evidence, the [Appellant] stated that he was told by Mrs MM that there was a treatment plan in respect of Patient A. In the NWAS investigation he stated that, “No treatment plan was discussed by the Physiotherapist”.• In his oral evidence, the [Appellant] stated that there was a discussion about Mrs MM travelling in the ambulance, that he knew why she wished to travel, but that he thought she presented a risk to Patient A. That account was wholly inconsistent with the account he submitted to NWAS under numbered paragraph 40 on 23 July 2018. What the [Appellant] did refer to in that paragraph was that he considered that Mrs MM would herself be exposed to risk were she to be permitted to travel in the rear of the ambulance.• With regard to Patient D, the description of the patient given in oral evidence that he was trying to climb out to the extent that he brought the stretcher up with him, did not accord with earlier accounts given by the [Appellant] of the patient’s behaviour.• Again, in relation to Patient D, in oral evidence, the [Appellant] stated that he had delegated the connection of the oxygen supply to Ms CP-J, but there was no mention by the [Appellant] of that delegation in the NWAS investigation in 2020. 28. These various factors had the effect that the Panel felt unable to accept the evidence of the [Appellant] save to the extent that what he said was the case was inherently likely to be correct or unless there was some corroborative material”.[66]Second, Ms Yeghikian argued that the Panel reasons for finding the facts proved against the Appellant were inadequate in that they did not address the inconsistencies in the evidence of the witnesses relied upon by the HCPC. I do not accept that submission: as [61] and [63] above make clear, the Panel gave detailed and careful reasons for their assessment of the witness evidence, including how the alleged inconsistencies impacted on that assessment.[67]As the caselaw summarised at [54]-[58] above makes clear, an appellant court will only allow an appeal against a finding of fact in “exceptional circumstances” and having applied the various deference thresholds: Byrne at [14] and Evboren at [33]-[35].[68]For the reasons set out above, I do not consider that any exceptional circumstances are present here. Applying the various deference thresholds and bearing in mind the meticulous way in which this particular Panel approached their task, there is no basis for interfering with their findings of fact.[69]Ground 1 is therefore dismissed.

Ground 2: Misconduct

[70]Under this ground the Appellant contended that the Panel’s finding of misconduct was unreasonable in a range of respects.[71]First, Ms Yeghikian submitted that the Panel had erred in finding that the Appellant was dishonest under charge 6. This provided that the Appellant had acted dishonestly by his conduct in charge 5(c), namely that on 11 July 2020 he had failed to keep adequate and/or accurate records in relation to Patient D in that he had recorded himself as having administered midazolam when this was not the case.[72]She argued that the Appellant had given a coherent, credible and reasonable explanation in respect of the recording of the midazolam administration, which the Panel was wrong to reject.[73]I cannot accept this submission.[74]The Panel’s comprehensive Decision make clear that they did not view the Appellant’s explanation as coherent, credible and reasonable. On the contrary, the Panel concluded that the evidence showed the Appellant had recorded himself as having administered midazolam when he had not done so; and that this was because he knew he had inappropriately delegated the administration of same to a junior colleague, and was attempting to cover that up. As the Panel explained: “85. For the Panel to answer why the [Appellant] incorrectly recorded himself as having administered the administration of Midazolam, the Panel first asked itself what it found about the [Appellant]’s understanding at the relevant time (i.e. 11 July 2020) about the restrictions concerning the administration of that medication resulting from the Patient Group Direction (“PGD”). The Panel had no hesitation in accepting the evidence of Mr NS that, as a proposition of fact, authority to administer granted under a PGD is not one that can be delegated. But the acceptance of that evidence did not mean that the [Appellant] knew on 11 July 2020 that the authority granted to him under the PGD was one that could not be delegated. To answer the objective “ordinary and decent people” question, there might be a world of difference between, on the one hand, positively knowing that delegation was not permitted, and, on the other hand, it being said that someone should have known.86. The Panel was satisfied that the [Appellant] received training on PGDs. The absence of that training from the NHS ESR record of training does not negate Mr NS’s clear evidence that the [Appellant] received training. The Panel is also satisfied that the [Appellant] knew at the material time that authority under a PGD was not one that could be delegated, as the restriction to senior staff with the required qualification is the very purpose of a PGD, to permit the administration of medication that is not within JRCALC guidelines. The Panel does not consider that the apparent ignorance of Ms CG (who administered the Midazolam) of the inability to delegate supports the [Appellant]’s case for the simple reason that she was not working at a level that qualified for inclusion in PGD authority.87. In the view of the Panel, the fact that the [Appellant] positively knew that he could not delegate the responsibility for administration of Midazolam explains why he falsely recorded himself as having administered it. It was an excessive dose. The desire to avoid it being apparent that it was administered by a person who was not permitted to do so is supported by the fact that the box against the words, “Tick if a PGD drug has been given” was not ticked.88. When the Panel asked itself the question whether ordinary and decent people would consider it to be dishonest for the [Appellant] to have recorded himself as having administered Midazolam when he did not, but he was the only person permitted to do so, the answer to that question was that they would”.[75]The Panel’s general, and highly critical, assessment of the reliability of the Appellant’s evidence set out at [65] above was also relevant at this juncture.[76]It is therefore clear that the Panel considered, but rejected, the Appellant’s explanation for why he had recorded the administration of the midazolam as he had. They were plainly entitled to do so. Bearing in mind, in particular, the principle of deference to the Panel’s role in considering the live evidence (see Evboren at [34] at [57] above), I see no basis for interfering with the Panel’s assessment.[77]Second, Ms Yeghikian submitted that the finding of misconduct was wrong because there were no policies in place at the time of the second incident in respect of the delegation of responsibility for administering drugs such as Midazolam; and indeed it had been “custom and practice” for many years to permit more junior colleagues to administer such drugs.[78]In my judgement, this submission is not sustainable: for the reasons the Panel gave at [85]-[87] they had received evidence, which they accepted, that the Appellant had been trained on the “PGDs”, which were the directions or policies which restricted the administration of certain medications to senior staff with the required qualifications: see [74] above. There is no proper basis for contending that the Panel was not entitled to accept this evidence.[79]Third, MsYeghikian contended that the finding of misconduct was wrong because there was no or insufficient evidence before the Panel in respect of how a Patient Report Form (“PRF”) should be completed; and because training in this task had only been introduced recently, after the second incident on 11 July 2020.[80]I cannot accept this submission.[81]The Panel fully engaged with the issue of how the Appellant could have been expected to complete PRFs, given his experience, and of how he had in fact completed the PRFs in respect of Patients A and D, as follows: “38. In the judgement of the Panel, the PRF completed by the [Appellant] in respect of Patient A was woefully inadequate for a practitioner of the [Appellant]’s seniority. Box 2, “History”, did not record the particular syndrome that Patient A had been diagnosed as suffering from. There was no reference to medication. In relation to particular 1(c) mention has already been made in the discrepancy between the oxygen saturation level of 89% communicated at 11:24:19, and the 96% recorded on the PRF at 11:25. In the judgement of the Panel, whichever value represented the true level of oxygen saturation at that time (and they cannot both have been correct), disclosure of the level communicated to the EOC should have been included in the PRF, and if the reading of 96% was a genuine reading, an explanation for it should have been given. A zero value for verbal re-sponse (as recorded by the [Appellant] on six occasions on the PRF) is not a value recognised for the purposes of the Glasgow Coma Score. Had the [Appellant] considered Mrs MM to present the risk to Patient A he claims he thought she did because of her inappropriate management at the school, that was also a matter that should have been recorded on the PRF… 76. In the judgement of the Panel, the history recorded in section 2 of the PRF [in respect of Patient D] was inadequate. The patient’s medical history is not recorded, and save for recently prescribed Lansoprazole, there is an absence of reference to whether the patient was taking medication. No rationale for the needle decompression is provided. As the patient was presumably unable to provide consent to being treated, there is no reference to a “best interests” justification for interventions. Furthermore, there is no evidence of airway assessment or management being performed despite it being apparent from the section 5 of the PRF that suction was performed and an I-Gel being placed. This was a complex case. A significant degree of detail and accuracy was required in order to ensure that the most effective care of Patient D could be provided once he was at the hospital… 78. In the view of the Panel there were omissions from the observations section of the PRF. The matters omitted included the absence of a NEWS score, no capillary refill recorded, the ETCO2 carbon dioxide recording was not included until 13 minutes after administration of morphine and 8 minutes after the administration of Midazolam. Furthermore, Patient D’s pupillary response/size was not recorded at any stage, and BM (blood sugar) was not recorded at any stage (a particularly significant omission as Patient D was recorded as being unconscious)”.[82]The Panel also noted at [75] that the Appellant had accepted in the internal NWAS investigation, on 20 July 2020, that the quality of his PRF in respect of Patient D was “very poor”.[83]Further, the Panel addressed, but rejected as “unconvincing”, the Appellant’s argument that he had been insufficiently trained in this issue: “39. In his evidence, the [Appellant] relied upon the fact that at no stage in his career as a Paramedic had he been trained in the how to complete a PRF. The Panel feels bound to say that it would find that an unconvincing argument for any Paramedic to mount. For an Advanced Paramedic it is an argument that lacks credibility. The role of Advanced Paramedic is one at Masters or postgraduate level. The [Appellant] gave evidence about his clinical and managerial responsibilities at NWAS, and the Panel is satisfied that as an Advanced Paramedic, he would have been regularly providing review and critical analysis of PRFs completed by other clinicians”.[84]Again, the Panel’s critical assessment of the reliability of the Appellant’s evidence in general, set out at [65] above, was relevant to this issue.[85]These were unimpeachable findings and again there is no basis for interfering with them on appeal.[86]I observe that although advanced under Ground 2, in the context of misconduct, these three arguments were, at least wholly or party, in reality challenges to the Panel’s factual findings with respect to dishonesty and the expectations, training and policies with respect to PRFs and PGDs. The additional thresholds that the Appellant would have to meet to succeed on such factual challenges and the deference principles derived from the caselaw set out at [54]-[58] above, therefore apply. In my judgement, the Appellant cannot meet them.[87]Fourth, in her written documents Ms Yeghikian made a suggestion of bias relating to one of the witnesses, John Collins. This was because it transpired that he had previously sat on a Panel with the Chair at a hearing in 2023.[88]However, it is not appropriate to seek to advance this point on appeal. This is because the issue was squarely raised with the parties in the course of the hearing and rejected on the Appellant’s behalf: Mr Irving confirmed on behalf of the HCPC that there was no issue with the Chair continuing in this matter’ and Ms Yeghikian specifically endorsed that submission, no doubt having discussed the issue with the Appellant: see the transcript for Day 4, 14 March 2025, at p.2 (p.758 of the hearing bundle). This may explain why this point was not pursued in oral submissions before me.[89]To the extent that the Appellant does still seek to rely on the point, I would reject it. Mr Cassells was right to characterise the link between the Chair and the witness as relatively tenuous, arising out of a single professional engagement approximately two years previously. On that basis, a fair-minded and informed observer would not conclude there was a real possibility of bias. Mr Cassells highlighted that in Prasad v General Medical Council [2015] EWHC 338, a similar point arose, albeit that there had been a much closer connection between the Chair and two witnesses, as the Chair had been their appraiser. Again, the parties had been afforded a proper opportunity to consider whether to ask the Chair to recuse himself and Dr Prasad’s counsel had expressed his willingness to proceed without qualification. There was no indication that this was other than a considered decision, with which Dr Prasad fully agreed. The same considerations apply here.[90]I observe that although advanced under Ground 2, if there was any force in the allegation of bias, it would surely apply to all elements of the Panel’s decision.[91]For all these reasons Ground 2 is dismissed.

Ground 3: Impairment

[92]Under Ground 3, the Appellant contended that the Panel’s decision with respect to impairment was wrong.[93]In Sayer v General Osteopathic Council [2021] EWHC 370 (Admin), Morris J reviewed the authorities on the relationship between contesting the charges and the insight, or lack thereof, shown by the professional. At [25], he identified 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: [GMC v 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 v GMC [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 (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 play 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”. “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 play close attention to the doctor’s current understanding of and attitude towards what he has done”.[94]Ms Yeghikian submitted that there was no evidence of current impairment nor a risk of repetitive behaviour in the Appellant’s case. She argued that the Panel had disregarded the overwhelming evidence of the Appellant’s good, honest and safe work both before and after the incidents in question.[95]I cannot accept this submission.[96]The Panel specifically “did not doubt” that the Appellant was capable of practising safely and effectively; and had, on the whole, done so in the past. They rightly identified the central issue for them as being whether he could be relied upon consistently to do so in the future: see [30] above.[97]In addressing that issue the Panel specifically acknowledged the evidence that there had been no concerns raised about his work in the preceding four years: see [30] above. However, they remained concerned that there was a common theme between the two incidents, namely an “attitudinal shortcoming” on the part of the Appellant; and their overall assessment of the Appellant was that this was unlikely to change. The Panel considered that even now, he did not have any real understanding of how serious his behaviour was and did not actually accept any wrongdoing: see [32] above.[98]Sayer at [25](4) makes clear that the Panel was entirely correct to take into account the Appellant’s attitude to the underlying allegations against him when assessing his insight. The Panel did not fall into the potential error identified inKhetyar at [49], cited in Sayer at [25](4), by imposing a sanction on the Appellant for his denial as such: on the contrary the Panel was at pains to acknowledge that the Appellant was free to advance whatever case he wished in the proceedings before them, but just made the accurate and fair point that his presentation before them gave them a good opportunity to assess his demeanour: see [33] above. This, in turn, enabled them to form a “current understanding of and attitude towards what he has done”, in order to determine the ongoing risk he posed, per Sayer at [25](4).[99]The assessment of the extent of the Appellant’s insight was pre-eminently a matter for the Panel: Sayer at [25](5). Here, the Panel’s assessment that the Appellant lacked full insight, such that there was a significant risk that he would “in the future choose to act outside clinical standards and professional expectations”, was one that they formed after a lengthy hearing, which included the Appellant giving evidence before them twice, for relatively long periods. They considered his evidence in the context of the other extensive evidence before them. Accordingly, this Panel was particularly well-placed to form this assessment and there is no basis for this Court to interfere with it.[100]Ms Yeghikian also drew support from R (Bevan) v General Medical Council [2005] EWHC 174 at [39] (which was cited with approval in R (Onwuelo) v General Medical Council [2006] EWHC 2739 (Admin) at [34]-[35]). There, Collins J observed that “insight” was not an “appropriate way of looking at a situation where there is no danger of any recurrence but there is a concern that there has not been necessarily a full acceptance of the facts which have been alleged against the doctor”. However, that was not the case here: while the Appellant had not fully accepted the facts alleged against him, the Panel did not accept that there was “no danger of any recurrence”: on the contrary, the Panel considered that there was such a risk: see [34] above.[101]She also relied on R (Vali) v General Optical Council [2011] EWHC 310 (Admin), where the Panel’s decision as to impairment was quashed on appeal. Part of Ouseley J’s reasoning was that it was “hard to conceive that somebody who is a continued risk to public safety or to public confidence in the competence and standing of the profession would have progressed as [the professional] has done”: [51]. However, this case does not generate any generally applicable principles: it was a finding made in the context of the specific facts of that case. These included that there had been a “serious…one-off oversight”, where the professional had progressed in her supervisory and teaching roles since the incident. That is a factually different scenario to the one present here. To the extent that this Appellant had progressed throughout his lengthy career to a senior Paramedic role, and had been working under conditions without difficulties for the four years or so before the hearing, the Panel was well aware of both those facts, and afforded them appropriate weight: see [30] above.[102]Overall, the Panel’s careful reasons at [106]-[113], set out at [26]-[34] above, illustrate a sound and logical basis for concluding that the Appellant’s fitness to practice was currently impaired.[103]For all these reasons it cannot be said that the Panel’s decision on impairment was wrong.

Ground 4: Sanction

[104]The nature of a decision on sanction in the regulatory context was described by the Court of Appeal in Bawa-Garba at [61] as follows: “…an evaluative decision based on many factors, a type of decision sometimes referred to as “a multi-factorial decision”…a mixture of fact and law…“a kind of jury question” about which reasonable people may reasonably disagree: Biogen Inc v Medeva Plc [1997] RPC 1 at 45; Pharmacia Corp v Merck & Co Inc [2001] EWCA Civ 1610, [2002] RPC 41 at [153]; Todd v Adams (t/a Trelawney Fishing Co) (The Maragetha Maria) [2002] EWCA Civ 509, [2002] 2 Lloyd's Rep 293 at [129]; Datec Electronics Holdings Ltd v United Parcels Service Ltd [2007] UKHL 23, [2007] 1 WLR 1325 at [46]”.[105]The Court continued: “It has been repeatedly stated in cases at the highest level that there is limited scope for an appellate court to overturn such a decision”.[106]The Appellant submitted the sanction imposed on him was disproportionate.[107]First,Ms Yeghikian drew support from the facts of Bawa-Garba and Odes v General Medical Council [2010] EWHC 552 (Admin). She is right that both of these cases involved medical professionals who were ultimately suspended rather than struck off their professional registers.[108]However, in Bawa-Garba, unlike in this case, the Tribunal had been satisfied that the risk of the professional putting a patient at unwarranted risk of harm in the future was low: [92]. That differs from the justified conclusion as to future risk in this case: see [34] above.[109]In any event, as Mr Cassells rightly highlighted, cases of this kind do not illustrate some kind of “tariff” in terms of the appropriate sanction for medical misconduct. Decisions on sanction are inevitably fact-specific. The only principle of wider application to be derived from Bawa-Garba is that given the multi-factorial nature of a regulatory panel’s decision on sanction, there is limited scope for an appellate court to intervene.[110]Second, Ms Yeghikian relied on R (Abrahaem) v General Medical Council [2004] EWHC 279 (Admin). There, Newman J allowed an appeal against a direction for erasure, substituting it with a sentence of 12 months’ suspension. At [39], he observed that: “It seems to me that one is entering into areas of excessive and disproportionate penalty if what one does is, in effect, assume that this doctor is quite incapable of having sufficient insight into the gravity of that which he did so as to lead to the risk that he would commit an offence such as this again. In my judgment, it is asking or inferring too much, from what I regard as his less than satisfactory evidence to the court in his statement, to conclude that he will not develop from this experience, and from what I would regard as an appropriate continuing penalty proportionate to the situation, sufficient and overall insight”.[111]Again, though, I cannot accept the submission that Abrahaem generates an overarching principle that “a lack of insight should not lead to an excessive and disproportionate penalty”. Abrahaem was a decision on its own facts. Further, paragraph 131 of the Sanctions Policy specifically recognises the scenario where a professional “lacks insight” as being one where a striking off order may be appropriate. The Policy also makes clear at paragraphs 20-23 that all sanctions need to be proportionate, in the sense of striking “a balance between the competing interests of the registrant and the HCPC’s overriding objective to protect the public”, dealing with the concerns raised, but also being “fair, just and reasonable”.[112]Third, Ms Yeghikian pointed to the Appellant’s long and distinguished career as a paramedic and his glowing testimonials. She emphasised that throughout the HCPC proceedings he had remained practising; he maintained full confidence if his employer; and he continued working up to the day of the decision on sanction. She argued that the Panel’s Decision failed to properly take into account his career history, including up to the day of the final hearing. In all the circumstances, a suspension order, rather than a striking off order, would have been the appropriate and proportionate sanction.[113]I cannot accept this submission.[114]As is clear from [31] above, the Panel specifically took into account his testimonials, but afforded them limited weight because they pre-dated the incident with Patient D.[115]Ms Yeghikian argued in her oral reply submissions that some of the testimonials before the Panel post-dated the incident with Patient D.[116]She referred to the evidence of Dr Anwar. He was the clinical lead of the service for which the Appellant was then working. The Appellant had given evidence to the Panel to the effect that Dr Anwar had conducted an audit of the Appellant’s more recent paperwork, had concluded that all was in order and had emailed the HCPC to this effect: see the transcript of the Appellant’s evidence on Day 12, 25 March 2025, at pp.7 and 9 (pp.986 and 988 of the hearing bundle). Two letters from Dr Anwar, dated 22 March 2022 and 1 March 2025, were also provided to the Panel. They confirmed the successful audit and were very positive about the Appellant’s work.[117]This evidence, with respect, addressed a different issue to that of the Appellant’s testimonials. It related to the issue of the Appellant’s work during the period of his suspension, which the Panel addressed separately, specifically acknowledging that there had been no difficulties with his work in period during this period, of just over 4 years: see [30] above: see [30] above. The views of Dr Anwar, quoted by the Appellant, do not therefore undermine the Panel’s conclusions with respect to the Appellant’s testimonials more generally.[118]Ms Yeghikian also referred to a testimonial from Donald Robson. He also gave evidence about working with the Appellant in the period leading up to the hearing, and so the same point as is made in the preceding paragraph applies.[119]As well as the Appellant’s testimonials and his more recent work, the Panel also took into account other factors on the Appellant’s behalf, namely that he had self-referred to the HCPC, had fully engaged in the fitness to practise process, had made some admissions and offered a limited apology and had undertaken some reflective work: see [43] above.[120]However, as the Panel acknowledged at [124], mitigating factors are likely to be less significant in this context than in courts considering retributive justice. This is because the overarching concern of regulatory proceedings is protection of the public. This principle is set out in the Sanctions Policy at [25].[121]Moreover, the Panel had identified a number of serious, aggravating factors, which had to be taken into account as well as those factors in the Appellant’s favour. These included the fact that the Panel was dealing with two incidents, the failings by the Appellant that were common to both, the fact that the second incident occurred when due to his employer’s warning the Appellant could have been expected to follow the proper standards, the element of dishonesty, involving an attempt to cover up the improper administration of a controlled drug, the risks to which the Appellant exposed Patients A and D, who were both vulnerable acutely unwell and his incomplete insight and reluctance to acknowledge wrongdoing: see [40]-[42] above.[122]The Panel carefully explained why they did not consider a suspension order, appropriate: “132…Paragraph 121 of the Sanctions Policy provides guidance about when a suspension order is likely to be appropriate. That paragraph states: “A suspension order is likely to be appropriate where there are serious concerns which cannot be reasonably addressed by a conditions of practice order, but which do not require the registrant to be struck off the Register. These types of cases will typically exhibit the following factors:• the concerns represent a serious breach of the Standards of conduct, performance and ethics;• the registrant has insight;• the issues are unlikely to be repeated; and• there is evidence to suggest the registrant is likely to be able to resolve or remedy their failings”. 133. This case does indeed represent a serious breach of the Standards of conduct performance and ethics, but that element apart, the present case does not fit the circumstances suggest suggested by the Sanctions Policy; the [Appellant’s] insight is limited, it cannot be said that the issues are unlikely to be repeated, and the fact that the second incident occurred while the [Appellant] was subject to a written warning and it is now nearly five years from that second incident with his insight still far from being developed, there can be no confidence that he would be able to resolve or remedy his failings. 134. The imposition of a suspension order would serve to protect the public from the risks that would arise were there to be repetition of behaviour of the sort found proved, but in the judgement of the Panel it would serve no other purpose because the risks presented at the conclusion even the maximum period of suspension would be exactly the same as they are now. Despite the length of time since the incidents occurred, the risk of recurrence is still present and there is insufficient reason to conclude that the [Appellant] would be able to address matters satisfactorily during the period of a suspension order. For that reason the panel concluded that a suspension order would not be appropriate”. “A suspension order is likely to be appropriate where there are serious concerns which cannot be reasonably addressed by a conditions of practice order, but which do not require the registrant to be struck off the Register. These types of cases will typically exhibit the following factors:• the concerns represent a serious breach of the Standards of conduct, performance and ethics;• the registrant has insight;• the issues are unlikely to be repeated; and• there is evidence to suggest the registrant is likely to be able to resolve or remedy their failings”.[123]In my judgement this was an unimpeachable application of the Sanctions Policy. The Panel rightly recognised that the first bullet point in support of a suspension order in paragraph 121 of the Policy applied. I cannot accept the Appellant’s submission that the Panel was wrong not to have found that all three further bullet points also applied. Rather, they were fully entitled, for the reasons they gave, to conclude that they did not. I do not consider that there is any proper basis on which I should interfere with this conclusion.[124]Indeed were I to do so, I consider that I would be falling into the error identified by Garnham J in Professional Standards Authority v(1) Nursing and Midwifery Council(2) Judge [2017] EWHC 817 (Admin) at [40]. There, he found that a Panel had engaged in “unsupported wishful thinking” as to the possibility of the registrant gaining insight whilst suspended, observing as follows: “…there was, in truth, no evidence, as opposed to unsupported wishful thinking, that given more time the Registrant might develop insight. The fact that she was a nurse of considerable unblemished experience does not assist the Panel in that regard, in my view. There was in the Registrant’s case no hard evidence at all that she would or might do so; by contrast there was evidence, in her response over the preceding two months, to support a conclusion that there was no sign of any such insight emerging”.[125]The Panel then clearly explained why a striking off order was appropriate, again by reference to the Sanctions Policy: “135…The Panel noted that in paragraph 130 [of the Sanctions Policy] dishonesty and failure to work in partnership are two of the examples given or serious cases that might result in a striking off order being made. It also noted that the guidance in paragraph 131 states that a striking off order is likely to be appropriate where the nature and gravity of the concerns are such that any lesser sanction would be insufficient to protect the public, public confidence in the professional, and public confidence in the regulatory process. 136. In considering whether a striking off order should be made, the Panel acknowledged the extremely serious nature of such an order the effect on any professional would be significant, in terms of career, reputation and the ability to earn their livelihood. For that reason it is right that striking off order should be reserved for the most serious cases, and then only when there is no other appropriate alternative. Nevertheless, having reminded itself of all these factors, the Panel was satisfied that a striking off order is indeed not only appropriate in the present case, but it is the only appropriate order. No lesser sanction would provide the degree of public protection required, and no lesser sanction would ensure that public confidence would be maintained, and no lesser sanction would declare proper professional standards and serve to remind other registrants of the serious view that would be taken where they do breach standards in the way the Appellant did. These factors outweigh the personal difficulties the panel acknowledges the Appellant will suffer as a result of the imposition of this sanction for that reason the panel is satisfied that it is a proportionate response to the findings made”.[126]Again, therefore, the Panel carefully applied the Sanctions Policy. In my judgement, they were entirely justified in concluding that three of the factors set out in the Policy that may justify a striking off order being made were present - namely dishonesty, a failure to work in partnership and this being a case where the nature and gravity of the concerns are such that any lesser sanction would be insufficient to protect the public, public confidence in the professional, and public confidence in the regulatory process. I therefore reject Ms Yeghikian’s submission that none of the paragraph 130 factors applied.[127]The Panel went on to give detailed consideration to the impact of a striking off order on the Appellant at [136]: see [124] above. While it is inevitably the case that the striking off order will have some adverse financial consequences for the Appellant, which Ms Yeghikian emphasised in her submissions, that does not of itself render the sanction imposed disproportionate. The Panel specifically considered the impact of striking off on the Appellant’s ability to earn a livelihood, and other factors relevant to the proportionality assessment. Again, I consider this an unimpeachable analysis: overall the Panel were entitled to conclude that a striking off order was proportionate.[128]For all these reasons I do not consider that the Panel’s decision with respect to sanction was wrong or unjust for the purposes of CPR 52.21(3). I therefore dismiss Ground 4.

Conclusion

[129]Accordingly, for all these reasons, this appeal is dismissed.[130]The Appellant is ordered to pay the Respondent’s costs, in accordance with the general rule set out in CPR 44.2(2)(a)that the unsuccessful party will be ordered to pay the costs of the successful party. The Appellant’s limited means, relied on by counsel in opposition to the making of a costs order, may be relevant to the time afforded to him to pay any costs order, but do not, in my judgement, justify displacing the general rule in CPR 44.2(2)(a).[131]Those costs are summarily assessed in the sum of £7,017.60. This was the amount claimed by the Respondent on its costs schedule. The Appellant did not advance any arguments to the effect that these costs were unreasonably incurred, unreasonable in amount or disproportionate to the matters in issue and I do not consider that they were. By consent, he has been given 6 months in which to pay the costs order.