Case No. CO/5249/2016 
Neutral Citation Number: [2017] EWHC 419 (Admin)
IN THE HIGH COURT OF JUSTICE
QUEEN'S BENCH DIVISION
THE ADMINISTRATIVE COURT 
Royal Courts of Justice 
Strand
London WC2A 2LL 

Date: Thursday, 26 January 2017
 
B e f o r e: 

MR JUSTICE DOVE 

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Between:
 
OKWUOLISA DUKE IGWILO 
Appellant

v 

THE GENERAL MEDICAL COUNCIL. 
Respondent 
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Dr R Wilcox (instructed by Carl Martin) appeared on behalf of the Appellant 
Mr I Hare (instructed by GMC Legal) appeared on behalf of the Respondent 
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J U D G M E N T S: (Approved)

(i) concerning appellant's skeleton
(ii) concerning adjournment
(iii) concerning application
RULING 
(i) Concerning the appellant's skeleton 
1.	MR JUSTICE DOVE:  This is an application to effectively amend the grounds of appeal in this case.  The original grounds of appeal were put on three bases: 
2.	Firstly, the refusal to adjourn the proceedings, which it was said was wrong.  
3.	Secondly, the decision to immediately suspend registration was submitted to be wrong.  
4.	Thirdly, it was submitted that the ultimate sanction arrived at by the panel in this case was one which was wrong and that the findings on which they based their conclusions did not merit the erasure of the appellant.
5.	A skeleton argument was served, it seems, yesterday afternoon. I received the skeleton argument a little after 10.45 am this morning.  In that skeleton argument, new points are raised in relation to an alleged misdirection as to the appropriate rules of the General Medical Council Fitness to Practise Rules 2004, upon on which the adjournment application proceeded.  
6.	It is submitted in the context of the new skeleton argument that rule 31 (as opposed to rule 29.2) was the relevant rule for the purposes of the assessment of the adjournment.
7.	Furthermore, submissions are made as to the voluntary erasure of the appellant which had been approved with effect from 29 February 2016 and therefore prior to the hearing before Lang J on 9 March 2016, and the implications of that voluntary erasure in terms of the status of the proceedings.  That is, as will be evident from what I have already said, a fresh point raised for the first time in this skeleton argument.
8.	The application to rely upon the new skeleton argument is resisted by Mr Hare on behalf of the respondent.  He draws attention to the fact that a judicial review application was issued in relation to the acceptance of the voluntarily erasure by the GMC and that that judicial review has been refused on the papers and certified as totally without merit.
9.	He also objects to reliance on new arguments, bearing in mind that that skeleton argument was chased by those who instruct him and in response, during the course of it being chased, the appellant's solicitor indicated that there was no prejudice to the respondent as they already had the appellant's grounds of appeal.
10.	In assessing the question of whether or not I should grant permission for this skeleton argument to be relied upon, I need to bear in mind the over‑riding objective and also the consequences which might arise were these new arguments to be deployed.
11.	In my view, this skeleton argument, raising these fresh grounds has arrived far too late in these proceedings.  It was due months ago.  In those circumstances, it seems to me there is a substantial hill for Dr Wilcox to climb to persuade me that these fresh arguments, unadvertised until close of play yesterday, should be sprung upon the respondent.
12.	I can see no sensible reason (and none has been offered) as to why this skeleton argument with its fresh material has been produced at such a late stage in the proceedings.  I am unprepared to imperil the hearing of this appeal today by granting the leave to rely upon these arguments to the extent that fresh and additional points are raised which would undoubtedly require commissioning of additional material; for instance, in relation to the dismissal of the judicial review.  In those circumstances, I am not proposing to grant permission for the skeleton argument to be relied upon.
13.	Dr Wilcox indicates that if that were to be my conclusion, he would wish to make an adjournment application.  I shall hear him now as to whether or not there are any particular reasons why this appeal should be adjourned and will then permit Mr Hare to respond to those submissions.  He has already indicated that he wishes to proceed today.
14.	(Counsel's submissions were heard by the learned judge)
15.	 
RULING
(ii) Concerning adjournment 
16.	MR JUSTICE DOVE:  Dr Wilcox has made submissions that this appeal should be adjourned on the basis that there was a failure of the panel to engage in the exercise required by paragraph 31 of the rules, that is to say, assessing prejudice to the appellant in proceeding in his absence along the lines of the principles in criminal law in relation to trial in the absence of a defendant.
17.	He submits that because that is a significant point in the appellant's case, it is a justification for adjournment. The opportunity to serve the skeleton argument, which I have already refused permission to rely upon could be admitted and the exploration of that argument undertaken.  Having explored the point with Dr Wilcox, I am satisfied that that is a submission which is not arguable.
18.	The reality here is that the appellant was represented, indeed represented by the same firm who instruct Dr Wilcox, at the panel's hearing.  When the panel had the application for an adjournment submitted to it, there was no reliance on any prejudice that might be caused to the appellant as a consequence of his absence.  
19.	The application to adjourn was put on separate bases to do with appeals against Lang J's order and also a submission that there would be judicial review of the decision to admit him to the Register after he had applied for voluntarily erasure.  
20.	Thus, the point that he has raised is not one that was before the panel as a basis upon which adjournment could properly be granted.
21.	It seems to me, therefore, it is not arguable that there was any error on the part of the panel in failing to engage with a point that was never raised by the competent representative who appeared before the panel on behalf of the appellant.
22.	In the circumstances, therefore, there is no justifiable basis for the adjournment.  I should add that this appeal has been listed for a significant period of time.  There is, in this court, a need to be mindful of the impact on other litigants and the other burdens of litigation on this court that is caused by court time being wasted by cases being adjourned and then having to be relisted.  That is a further factor which, in my view, tells in favour of the application for adjournment being dismissed and I do so. Thank you.   
(A matter was interposed in the court) 
RULING 
(iii) Concerning the application 
23.	MR JUSTICE DOVE:  This is an appeal which is brought pursuant to section 40 of the Medical Act 1983, in relation to a decision which was reached by the Medical Practitioners Tribunal, (the MPT), in relation to the question of sanction in the case of the appellant following a finding by this court that an earlier conclusion reached by an earlier panel considering the appellant's case was unduly lenient and that his fitness to practise was impaired.  After a hearing on 15 to 16 September 2016, the appellant was erased from the Register and a decision was made that he should be immediately suspended pending any appeal.
24.	The factual circumstances of the appellant's case are as follows and, for the purposes of setting out that factual background, I am indebted to Lang J who reached an earlier decision in respect of this case in a judgment handed down on 15 March 2016. She set out the background prior to her involvement in the following paragraphs: 
[...]
"3. Dr Igwilo qualified as a doctor at the University of Nigeria Teaching Hospital in 1997, and registered with the GMC in 2002. He obtained his membership of the Royal College of Psychiatrists in 2006, as well as an MSc. At the time at which the incidents of misconduct occurred, he was employed as a locum consultant psychiatrist in the private sector. He was also undertaking a placement at Broadmoor to gain further expertise in forensic psychiatry.
4.  Dr Igwilo applied to the GMC for a Certificate of Eligibility for Specialist Registration (CESR) for entry in the Specialist Register of Forensic Psychiatrists, which would qualify him for appointment as a consultant.  In support of the application, he was required to submit a portfolio of work demonstrating that he had the requisite knowledge, skill and experience.  The evidence has to be validated.
5.  Dr Igwilo's first application in July 2010 was unsuccessful.  He was sent a detailed decision on 1 April 2011 which made seven recommendations.  Dr Igwilo exercised his right to apply for a review of the GMC's decision on 29 June 2011, but this was also unsuccessful.  The decision letter of 1 November 2011 made four recommendations.
6.  Dr Igwilo re‑applied on 15 November 2012, submitting inter alia further evidence to address the recommendations in the letter of 1 November 2012.  The GMC noticed that one of the reports which was signed by him had also been submitted by another applicant as his own.  In the course of the investigation, Dr Igwilo misled the GMC about the provenance of the report.  He also claimed that all the other reports he had submitted were his own work.  On 29 January 2013, he withdrew his application by email."
25.	Following that, there was an investigation by the GMC and a number of allegations were laid against the appellant.
26.	In her decision, Lang J sets out in detail the findings which the panel made which included findings of dishonesty. The panel concluded (notwithstanding the misconduct findings that they had made) that Dr Igwilo's fitness to practise was not currently impaired and therefore that brought the consideration of these matters to a close. They based that conclusion on the fact that it was an isolated piece of dishonesty which they had found and one which occurred against a background of severe personal stress. They relied upon the extensive reflection and mediation and insight of the appellant in reaching their conclusion as to no impairment.  But that conclusion was considered by the Professional Standards Authority for Health and Social Care to be one which was unduly lenient and they made the application which came on before Lang J on 15 March 2016.
27.	Unknown to Lang J, prior to her considering the matter, the appellant had made an application on 15 February 2016 for voluntarily erasure from the Medical Register.  At the time of the application being considered, the Registrar was unaware of the detail of the case which was proceeding against him.  The application for voluntarily erasure was granted to the appellant and he was therefore effectively voluntarily erased at the time of Lang J's hearing.  
28.	Lang J's decision in relation to the PSA's application is reported as The Professional Standards Authority for Health and Social Care v The General Medical Council & Anor [2016] EWHC 524 (Admin). Having set out the principles under which it was necessary for her to consider the application, she found the following in particular in relation to ground 2 of the application:
"27.The Panel was entitled, if it thought it appropriate to do so, to place weight on Dr Igwilo's mitigation, and to accept his evidence, supported by character references, that this was an isolated period of dishonesty which occurred at a particularly stressful time for him, and that he had since undergone an extensive period of reflection and remediation, which meant that there was no risk of repetition.
28. However, I consider that the Panel was unduly lenient in concluding that Dr Igwilo's fitness to practise was not currently impaired, given the very serious and sustained deception of the regulator which he embarked upon, purely to advance his career. He falsified a large number of documents: 24 documents described as reports in respect of different patients, 5 documents described as reports for Courts or Tribunals in respect of different patients, 7 sets of documents described as section 48 paperwork for different patients, 1 set of documents described as section 37 paperwork, 4 referral letters, 2 letters to patients' general medical practitioners and correspondence confirming appointments and placements and other correspondence. The scale of the falsification indicated it was an elaborate deception which must have taken some considerable time to plan and implement. His dishonesty affected his professional colleagues, as he represented their work as his own, or claimed that they had approved of his work when they had not done so.
29. The Panel was overly generous in accepting his submission that when his deception came to light he admitted his guilt and apologised immediately. Before his deception came to light as a result of independent investigation by the GMC, he maintained the falsehood. From the evidence, it appears that he only admitted his guilt and apologised once he realised that he was going to be exposed. He did not confess to the falsifications of the other documents until later, once the disciplinary proceedings were brought against him.
30. Dishonesty constitutes a breach of a fundamental tenet of the profession of medicine: honesty, openness and integrity are listed amongst the fundamental duties of doctors in 'Good Medical Practice' and being honest and trustworthy and acting with integrity are described by 'Good Medical Practice' as being at the heart of medical professionalism. Plainly cases of dishonesty vary in severity; in my view, this case was at the more serious end of the scale.
31. The purpose of the Specialist Medical Lists and the GMC's regulation of them is to protect the public interest, including the safety of patients, and in the case of forensic psychiatrists, to maintain the standards of expert evidence submitted in court cases. Dr Igwilo's applications had not met the required standard for the Specialist Register of Forensic Psychiatrists on two previous occasions. He responded to the guidance given by the GMC as to how he might improve his prospects of success by using deception and deceit to try to obtain inclusion in the list when he was unable to do so by legitimate means. Such conduct jeopardised the integrity of the Specialist Medical List system, and the GMC's ability to regulate it. In my judgment, the Panel did not sufficiently recognise the seriousness of these factors, and indeed, made no mention of them.
32. I consider that the Panel made an error of judgment in concluding that the need to maintain public confidence in the profession and the regulator, and to declare and uphold proper standards of conduct and behaviour, was met by the fact that Dr Igwilo had been subject to fitness to practise proceedings and that he had shown insight and remorse. I do not consider that a Panel, properly directed, could reasonably reach such a decision on the facts of this case."
29.	In the light of those findings, Lang J allowed the appeal, quashed the panel's decision on an impairment; substituted a decision that the appellant's fitness to practise was impaired; and remitted the question of sanction to be determined by a freshly constituted panel.  
30.	After her decision had been handed down, on 28 April 2016, the Head of Registration Applications wrote to the appellant in the following terms in respect of his application for voluntarily erasure:
"When you made your application for voluntarily erasure in February 2016, you did not make clear that you were subject to the [PSA] proceedings, which had been issued on 23 October 2015, or that they had been listed in November 2015 for hearing before the High Court in March 2016.  
This was not information of which the Assistant Registrar, who considered your application was, or could otherwise have been aware [...]  Accordingly, the decision of the Assistant Registrar to grant your application for voluntarily erasure was made on the basis of a fundamental misunderstanding as to the then current status of your fitness to practise proceedings [...]  We will accordingly take immediate steps to restore your name to the Medical Register.  We will then refer your case back to the MPTS for them to list a hearing before a freshly constituted Medical Practitioners Tribunal, in accordance with the Order of Lang J dated 15 March 2016."
31.	Thus, when the matter came on before the MPT on 15 and 16 September 2016, the appellant had been restored to the Register.  He was not present at the hearing but was represented by Mr Nguwuocha of his solicitors.  On the appellant's behalf, an application to adjourn was made.
32.	The record of the MPT's determination provides as follows: 
"Application for an adjournment.
7. You, on behalf of Dr Igwilo, have applied for the tribunal to adjourn this hearing under rule 29(2) of the General Medical Council's (Fitness to Practise) Rules 2004.  That rule provides that: 
    'Where a hearing of which notice has been served on the practitioner in accordance with these Rules has commenced, the [...] considering the matter may, at any stage in their proceedings, whether of their own motion or upon the application of a party to the proceedings, adjourn the hearing until such time and date as they think fit.'
8. In considering your application, the tribunal has considered all of the evidence placed before it at this stage of the proceedings, namely the judgment of Lang J in The PSA v [1] GMC and [2] Okwuolisa Duke Igwilo [2016] EWHC 524 (Admin) ‑ and a chronology of events.  The tribunal also took account of the submissions made by you and those made by Mr Jackson QC on behalf of the GMC.  
9.  You submitted that the tribunal should adjourn the hearing as legal challenges are being pursued both in relation to Lang J's determination to remit Dr Igwilo 's case back to this tribunal, and to the GMC's action of the re‑registering the doctor on 28 April 2016.  You further submitted that there are therefore "pending appeals", which if successful would mean the tribunal, would have no jurisdiction to consider a sanction.
10. Mr Jackson opposed your application.  He submitted that that the decisions being challenged were not pending appeals but pending applications for leave to appeal.  He submitted that there can be no presumption that leave to appeal would be granted.  He highlighted that there has been no indication as to when Dr Igwilo will get a decision on those applications.  He emphasised that the case is now a year old and is the subject of Lang J's judgment.  He submitted that it would not be in the public interest to adjourn the hearing.
11. Whilst the tribunal has noted the submissions made it has exercised its own judgment when determining whether or not to adjourn the hearing. 
12.  Throughout its deliberations, the tribunal was mindful of the overarching objective set out in the Medical Act 1983 (as amended).  That overarching objective is the protection of the public and involves the pursuit of the following:
A.  To protect, promote and maintain the health, safety and wellbeing of the public.
B.  To maintain public confidence in the profession.
C.  To promote and maintain proper professional standards in conduct for members of that profession.  
13.  In reaching its decision, the tribunal bore in mind the need to be fair to both parties ‑ the doctor and the GMC as the regulator.  The tribunal balanced Dr Igwilo's interests with the public interest, which includes an expectation of cases which come before a tribunal will be heard expeditiously and without undue delay. 
 [...] 
15. The tribunal considered the background summarised above.  It has had regard to the fact that the original hearing took place in September 2015, with the appeal judgment being given in March 2016.  There is no evidence to show that if the tribunal were to grant an adjournment the situation before a  future tribunal would be any different.  
It has noted that there is no known timeframe in relation to how long the application Dr Igwilo has made for permission to appeal will take to be considered.  It has borne in mind that if the challenges the doctor seeks to make are successful then any decision this tribunal makes in relation to sanction will fall away.  The tribunal does not consider that proceeding with the case would result in unfairness to either party. 
Dr Igwilo would not be significantly disadvantaged if this tribunal were to proceed as he is able to present his case on the issue of sanction.  Having considered all the circumstances, the tribunal determined that it is in the public interest that this tribunal should proceed expeditiously."
33.	The record of the MPT's determination goes on to record the facts which were found by the panel in September 2015 as to the documentation which had been dishonestly prepared and which is reflected in the passages from Lang J's judgment, which is also alluded to in the record of the determinations. The tribunal went on to assess its task, namely determining the appropriate sanction in this case.  The tribunal took account of a note prepared by the appellant reflecting on what had taken place, and observing that what had happened occurred as a consequence of 'stress and burn out' at the time when the acts complained of occurred.  That note, of which the panel took into account, also expressed his regret and remorse as to what had occurred. During the course of the record of their determination, the submissions of both parties are recorded.  It is unnecessary for me to set them out for the purposes of this judgment.
34.	The MPT then embarked on an iterative consideration of the appropriate sanction which should be imposed in this case.  They first determined at paragraph 23 of their decision that to take no action "would be wholly inappropriate" in the light of the nature of the appellant's conduct.  Similarly, when considering whether conditional registration would meet the case, they concluded that that would not:
35.	"Adequately reflect the seriousness of the tribunal's findings, nor would conditions be workable or measurable."  
36.	They then went on to assess whether or not suspension would be an appropriate sanction.  It is worthwhile setting out in full the conclusions which they reached in relation to suspension, since they led the MPT to the conclusion that erasure was the only appropriate sanction.  Their conclusions with respect to suspension were set out in the following terms:
"29. In reaching its decision on sanction, the tribunal balanced the mitigating factors with the aggravated factors in Dr Igwilo's case.  
30.  The tribunal considered the following to be mitigating factors in Dr Igwilo's case: 
•   Dr Igwilo has made a number of admissions in relation to the facts of his case and conceded that his fitness to practise was impaired at the time of the events;
•   Dr Igwilo was of previous good character.
•   Dr Igwilo has not repeated his misconduct;
•   Dr Igwilo has made reflections on his misconduct and his efforts to remediate it, in so far as it is remediable;
•   Dr Igwilo has made expressions of remorse and regret and has demonstrated an insight, albeit limited, and. 
•   Dr Igwilo has submitted evidence that he was suffering from 'stress and burn out'. 
31.  The tribunal considered the following to be aggravating factors in Dr Igwilo's case: 
•   Dr Igwilo's dishonest actions were a significant departure from the principles set out in good medical practice; 
•   Dr Igwilo's dishonesty was of a large scale and involved elaborate planning;
•   Dr Igwilo's dishonesty was deliberate, significant and sustained over a significant period of time required to compile the documentation; 
•   Dr Igwilo's dishonesty affected his professional colleagues; 
•   Dr Igwilo's dishonest actions were for personal gain;
•   Dr Igwilo failed to be open and honest with the GMC, despite being challenged by them; and 
•   Dr Igwilo's misconduct had the potential to cause harm to patients, in that, had his dishonesty not been recognised it could have resulted in his being grant at Certificate of Eligibility for Specialist Registration, which could have enabled him to obtain a substantive consultant position which he was not qualified or entitled to undertake.  
32.  Dr Igwilo dishonest actions have seriously undermined the GMC's primary responsibility to protect patients and maintain public confidence in the profession and to declare and uphold proper standards of conduct and behaviour.  
33.  The tribunal was of the view that the dishonest behaviour which was resulted in Dr Igwilo's misconduct and impaired fitness to practise was so serious as to be fundamentally incompatible with continued registration and that a period of suspension would not adequately reflect the seriousness of the tribunal's findings."
37.	As a consequence, therefore, having excluded all other means of disposal of the case, the MPT concluded that erasure was the only appropriate sanction. In doing so, there was reference made by the MPT to the guidance provided to the MPT on the imposition of sanctions.  In particular, at paragraph 82, of the guidance, the following is provided: 
"82. Erasure may well be appropriate when the behaviour involves any of the following factors (this list is not exhaustive):
    a. Particularly serious departure from   the principles set out in Good Medical Practice i.e behaviour fundamentally incompatible with being a good doctor.  
    b. A reckless disregard for the principles set out in Good Medical Practice and/or patient safety.
    [...]  
    d. Abuse of position/trust (see Good Medical Practice paragraph 65 'you must make sure that your conduct at all times justifies your patients' trust in you and the public's trust in the profession'. 
   [...] 
    h. Dishonesty, especially where persistent and/or covered up [...]
    i. Putting an interest before those of patients (see Good Medical Practice ‑ 'Make the care of your patient your first concern'.
   [...]
   j. Persistent lack of insight and seriousness of actions or consequences."  
38.	Thus, the conclusion was reached that in the light of the principles and guidance provided by the Sanctions Guidance at paragraph 82, the only proportionate and proportionate sanction was erasure. There was a further order made that the appellant should have his registration suspended pending the outcome of any appeal.
39.	The relevant legal principles in relation to an application of this kind are well established and well known.  They are governed by, in particular, the legal authority of the case Fatnani & Anor v General Medical Council [2007] 1 WLR 1460.
40.	Lord Justice Laws LJ set out at paragraphs 19 to 20 the relevant test: 
"19. [...] As it seems to me the fact that a principal purpose of the Panel's jurisdiction in relation to sanctions is the preservation and maintenance of public confidence in the profession rather than the administration of retributive justice, particular force is given to the need to accord special respect to the judgment of the professional decision‑making body in the shape of the Panel.
 [...]
20. [...] the High Court will correct material errors of fact and of course of law and it will exercise a judgment, though distinctly and firmly a secondary judgment, as to the application of the principles to the facts of the case." 
41.	It follows that the exercise which I have to undertake is establishing whether or not the sanction which was imposed was wrong.  It is not the task of the court to re-sentence or re-administer the sanction and reach a fresh decision. It is, as Laws LJ observed, a secondary judgment and one in which a particular respect has to be afforded to the expert tribunal who forged the initial conclusion as to the appropriate sanction.
42.	This appeal was brought on the basis of appeal grounds settled at the time when it was issued.  In separate decisions, I have dismissed the appellant's application to rely upon fresh grounds furnished, within a skeleton argument served yesterday and  also declined an application to adjourn this case so as to enable that fresh skeleton to be served and the argument contained within it to be developed.  
43.	The appeal grounds which are before me are three in number: 
44.	In Ground 1, it is submitted on behalf of the appellant that it was wrong and unfair for the appellant's application to adjourn the proceedings before the MPT to be dismissed. It is submitted that in were good and sound reasons for the application to be adjourned which were advanced in the context of the hearing, namely the pending appeal against Lang J's order and the application in relation the application for judicial review in relation to the reinstatement of the appellant on the record. Ground 2 is that it was excessive, disproportionate and wrong for the panel to order the sanction of erasure in the present case.  It is submitted that there was substantial mitigation identified in the earlier consideration of fitness to practise in September 2015, which had an important and weighty bearing on whether or not it was appropriate for the sanction in this case to be one of erasure. Finally, Ground 3 is the contention that an order that immediately suspended the appellant was unnecessary and disproportionate. It was unnecessary on the basis that the appellant was no longer in medical practice having relocated to Nigeria and, in the circumstances, was not required.
Conclusions 
45.	Having set out in detail both the basis on which the adjournment application was made and the MPT's reasons for granting it, I am entirely satisfied there was no legal error at all in the conclusions which they have reached. As was submitted to them on behalf of the GMC, what they were presented with were not pending appeals but applications for permission to appeal.  In short, therefore, no appeal was on foot in relation to Lang J's order and no permission had been granted in respect of any application for judicial review of the decision to restore the appellant to the Register. Thus, those matters which were placed before the panel were of limited status and, in my judgment, of inconsequential weight when measured against the need for the proceedings to be resolved and the public interest in a determination of the question of sanction following Lang J's decision. The MPT, in my judgment, carefully weighed those competing considerations and reached a conclusion which I will venture to suggest was not only open to them but was, in truth, the only appropriate decision in the circumstances of the case. I therefore do not consider that there is any substance in the first ground of this application, namely, that the panel erred in law in failing to adjourn the proceedings and their failure to do so gave rise to unfairness to the appellant. As the MPT observed, the appellant was represented and was able to make all submissions that he or his representative thought were appropriate to the MPT.  Indeed, as I have pointed out in connection with the application to adjourn before me, no submission was recorded by the MPT that the presentation of the appellant's case was in any way hampered or impeded by the circumstances in which the hearing proceeded.
46.	I turn, then, to the question of Ground 2. The background to that assessment must be the paragraphs of Lang J's judgment, namely paragraphs 27 through to 32, in which she set out what she characterised as a case of dishonesty, in her view at the more serious end of the scale. She also observed the persistent nature of the dishonesty which had taken place on several occasions.  That was what led her to the conclusion that the appellant's fitness to practise had been impaired.  That was therefore the backdrop to the assessment of the appropriate sanction in the appellant's case. Whether or not erasure was the right response to those matters which were recorded by Lang J has to be gauged against the guidance which I have set out from paragraph 82 of the Sanctions Guidance. When that is undertaken, a very similar balancing exercise to that which was recorded by the MPT in the record of their determinations from paragraphs 29 to 33, which I have set out above, occurs. It is clear to me that the MPT had regard to all of the relevant features of this case, which could be taken into account for and against the appellant when examining the appropriate sanction. Having set out all of those factors, I have no difficulty in accepting the panel's conclusion that no other sanction (apart from erasure) was appropriate to meet the appellant's case.  For the reasons which they gave, I am entirely satisfied that their decision was one which was appropriate, and which should be upheld in this appeal.
47.	I turn then, finally, to the question of immediate suspension.  I do not consider that there is any substance in the complaint raised that the appellant had no intention of practising and that such an order was unnecessary.  Given the gravity of the matters which had been found against the appellant, and the seriousness of the sanction to which he was subject, in my view it was entirely necessary and appropriate for the panel to immediately suspend the registration of the appellant.  That was both proportionate and necessary given the appellant's previous conduct as found by Lang J, and I see no error in the decision which the MPT reached in that connection.  
48.	It follows for all of the reasons which I have given that this appeal must be dismissed.