Dr Muhammad Asad Haroon v General Medical Council

MRS JUSTICE FARBEY DBE: Introduction

1. This is an appeal under section 40 of the Medical Act 1983 (“ the Act ”) against the decision of a Medical Practitioners’ Tribunal (“the MPT” or “the Tribunal”) to erase the appellant’s name from the Medical Register. The proceedings before the Tribunal concerned the appellant’s fitness to practise as a doctor following his conviction in the Crown Court at Swansea for one offence of controlling or coercive behaviour against his wife, contrary to section 76(1) of the Serious Crime Act 2015 .

2. The Tribunal concluded that the appellant’s fitness to practise was impaired by reason of the conviction. The appellant does not challenge that conclusion. His grounds of appeal are limited to an appeal against sanction. He submits that the MPT ought to have suspended him, and should not have erased his name from the Register.

3. The appellant was represented by Counsel before the MPT. Appearing before me in person, he advances three grounds of appeal: i. Ground 1 : The Tribunal failed to balance the aggravating and mitigating factors of the case appropriately when determining sanction. ii. Ground 2: The Tribunal failed to apply correctly the relevant guidance on sanctions and relevant legal precedents. iii. Ground 3: The Tribunal therefore erred in its determination of sanction.

4. On behalf of the General Medical Council (“GMC”), Mr Jack Anderson (who did not appear below) resists the appeal and submits that the Tribunal was entitled to conclude that erasure was the only appropriate sanction. He submits that such a sanction was not excessive or disproportionate on the facts of the case. Legal framework

5. Section 1 (1A) of the Act stipulates that the overarching objective of the GMC in exercising its functions is the protection of the public. By virtue of section 1 (1B), the pursuit of the overarching objective involves the pursuit of the following three objectives (which I shall refer to in this judgment as “the three elements”): “(a) to protect, promote and maintain the health, safety and well-being of the public, (b) to promote and maintain public confidence in the medical profession, and (c) to promote and maintain proper professional standards and conduct for members of that profession.”

6. Section 35 C(2) of the Act provides that a person’s fitness to practise shall be regarded as “impaired” by reason only of various specified matters, including (a) misconduct; (b) deficient professional performance; (c) a conviction for a criminal offence; and (d) adverse physical or mental health.

7. Section 35 D of the Act provides in so far as relevant: “35D.— Functions of a Medical Practitioners Tribunal … (2) Where the Medical Practitioners Tribunal find that [a person’s]… fitness to practise is impaired they may, if they think fit— (a) except in a health case, direct that the person's name shall be erased from the register; (b) direct that his registration in the register shall be suspended (that is to say, shall not have effect) during such period not exceeding twelve months as may be specified in the direction…”

8. Section 40 of the Act provides in so far as relevant: “40.— Appeals (1) The following decisions are appealable decisions for the purposes of this section, that is to say— (a) a decision of a Medical Practitioners Tribunal under section 35 D above giving a direction for erasure, for suspension or for conditional registration or varying the conditions imposed by a direction for conditional registration; … (4) A person in respect of whom an appealable decision falling within sub section (1 ) has been taken may, before the end of the period of 28 days beginning with the date on which notification of the decision was served under section 35 E(1) above, … appeal against the decision to the relevant court. … (7) On an appeal under this section from a Medical Practitioners Tribunal, the court may— (a) dismiss the appeal; (b) allow the appeal and quash the direction or variation appealed against; (c) substitute for the direction or variation appealed against any other direction or variation which could have been given or made by a Medical Practitioners Tribunal; or (d) remit the case to the [Medical Practitioners Tribunal Service] for them to arrange for a Medical Practitioners Tribunal to dispose of the case in accordance with the directions of the court, and may make such order as to costs… as it thinks fit.”

9. CPR 52.21(3) applies and means that the High Court will allow an appeal where the decision of the MPT was (a) wrong; or (b) unjust because of a serious procedural or other irregularity in the proceedings in the MPT. By virtue of CPR PD 52D, para 19.1, the appeal is by way of re-hearing. It is now established that the court is required to exercise its own judgment as to whether the sanction was wrong. In considering this question, the court must ask whether the sanction imposed was appropriate and necessary in the public interest, or whether it was excessive and disproportionate ( Sastry v GMC [2021] EWCA Civ 623 , [2021] 1 WLR 5029 , paras 110, 112 and 114).

10. The court must at the same time give “appropriate deference” to the determination of the MPT as a specialist tribunal which makes decisions within a specialist regulatory framework ( Sastry , para 112). I accept for present purposes in the appellant’s favour (without deciding the point) that the court is more equipped to assess the appropriate sanction for itself, and may give less weight to the expertise of the MPT, where the underlying charge found proved against the appellant concerns spousal abuse and violence rather than professional performance. The outcome of the present appeal does not, in any event, depend on some refined analysis of this court’s role.

11. Both parties referred me to Sayer v General Osteopathic Council [2021] EWHC 370 Admin , para 25, in which Morris J summarised the approach to be taken to a person’s insight into their misconduct when he or she continues to deny misconduct which a disciplinary tribunal has found proved: “As regards the relationship between contesting the charges and insight, I have been referred to a number of authorities: including Nicholas-Pillai v GMC [2009] EWHC 1048 (Admin) at §19; Amao v Nursing and Midwifery Council [2014] EWHC 147 (Admin) at §§160 to 164; Motala v GMC [2017] EWHC 2923 (Admin) at §§30, 31 and 34; Yusuff v GMC [2018] EWHC 13 (Admin) at §§18 to 20; GMC v Khetyar [2018] EWHC 813 (Admin) at §49; GMC v Awan [2020] EWHC 1553 (Admin) at §38 and Dhoorah v Nursing and Midwifery Council [2020] EWHC 3356 (Admin) at §36. From these, I draw the following principles: (1) Insight is concerned with future risk of repetition. To this extent, it is to be distinguished from remorse for the past conduct. (2) Denial of misconduct is not a reason to increase sanction: Awan §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 §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.”

12. As expressed by Yip J (as she then was) in Yusuff v GMC [2018] EWHC (Admin), para 18, it would be wrong to equate maintenance of innocence with a lack of insight. Admitting the misconduct is not a condition precedent to establishing that a person understands the gravity of the offending and is unlikely to repeat it ( Yusuff , para 20). Sanctions guidance Purpose of sanction

13. There is GMC-approved guidance to tribunals on imposing sanctions on a doctor’s registration. The Sanctions Guidance applied by the MPT in the present case is dated 5 February 2024 (“the Guidance”). This states that “[t]he main reason for imposing sanctions is to protect the public” (para 14) and that “[s]anctions are not imposed to punish or discipline doctors, but they may have a punitive effect” (para 16). Proportionality

14. The Guidance makes plain that a tribunal should have regard to the principle of proportionality (para 20). In order to ensure that the sanction is proportionate, a tribunal should consider the sanctions available, starting with the least restrictive. It should weigh the interests of the public against those of the doctor (para 20). However, once the tribunal has determined that a certain sanction is necessary to protect the public (and is the minimum required to do so), that sanction must be imposed, even where this may lead to difficulties for a doctor. This approach flows from the legal duty to protect the public (para 21).

15. The Guidance states at para 17: “Although the tribunal should make sure the sanction it imposes is appropriate and proportionate, the reputation of the profession as a whole is more important than the interests of any individual doctor.” Mitigating and aggravating factors

16. The Guidance deals with mitigating and aggravating factors to consider when deciding on a sanction. It states at para 24: “The tribunal is less able to take mitigating factors into account when the concern is about patient safety, or is of a more serious nature, than if the concern is about public confidence in the profession.”

17. The Guidance gives examples of mitigating factors. They include: i. Remediation : Evidence of attempts to reduce or remediate the problem (para 25). Remediation can take a number of forms, including coaching, mentoring, training and rehabilitation and, where fully successful, will make impairment unlikely (para 31). ii. Insight : Evidence that the doctor understands the problem and has insight (para 25) as demonstrated by “reflection and remediation” (para 45). iii. Character and previous history : This may include evidence that the doctor has not previously been found to have impaired fitness to practise by a tribunal (para 25). iv. Personal and professional matters : This includes work-related stress (para 25).

18. Taking steps such as admitting facts relating to the case, apologising to the patient, and making efforts to prevent behaviour recurring will demonstrate both remediation and insight (para 25).

19. The Guidance makes plain that, while doctors may present references and testimonials to support their good standing in the community and profession, the weight to be given to these documents is a matter for the tribunal (para 34). In considering whether such documents carry weight, the tribunal must consider whether the testimonial is relevant to the specific findings the tribunal has made about the doctor and the extent to which the views expressed in the testimonial are supported by other available evidence (para 39). Good testimonials are not on their own indicative of any particular sanction but must be weighed in the context of the case as a whole (para 40).

20. Aggravating factors that are likely to lead to a more serious sanction include misconduct involving violence or offences of a sexual nature (para 56). Lack of insight is listed as an aggravating factor (para 50). Treatment of criminal convictions

21. Where fitness to practise proceedings are based on a criminal conviction, the purpose of MPT proceedings is not to punish the doctor for the offence for a second time but to consider whether the doctor’s fitness to practise is impaired as a result (para 116). The tribunal should bear in mind that the sentence imposed by the criminal court is “not necessarily a definitive guide to the seriousness of the offence” (para 117). There may have been personal circumstances that led the court to be lenient (para 117). Suspension

22. The Guidance deals with the circumstances in which suspension of a doctor’s registration is appropriate, stating that: “91. Suspension has a deterrent effect and can be used to send out a signal to the doctor, the profession and public about what is regarded as behaviour unbefitting a registered doctor. Suspension from the medical register also has a punitive effect, in that it prevents the doctor from practising (and therefore from earning a living as a doctor) during the suspension, although this is not its intention.

92. Suspension will be an appropriate response to misconduct that is so serious that action must be taken to protect members of the public and maintain public confidence in the profession. A period of suspension will be appropriate for conduct that is serious but falls short of being fundamentally incompatible with continued registration (ie for which erasure is more likely to be the appropriate sanction because the tribunal considers that the doctor should not practise again either for public safety reasons or to protect the reputation of the profession)…

97. Some or all of the following factors being present (this list is not exhaustive) would indicate suspension may be appropriate. … e. No evidence that demonstrates remediation is unlikely to be successful, eg because of previous unsuccessful attempts or a doctor’s unwillingness to engage . f. No evidence of repetition of similar behaviour since the incident. g. The tribunal is satisfied the doctor has insight and does not pose a significant risk of repeating behaviour” (emphasis added). Erasure

23. Erasing a doctor’s name from the medical register may be imposed where this is the only means of protecting the public (para 107). Erasure may be appropriate even where the doctor does not present a risk to patient safety but where this action is necessary to maintain public confidence in the profession (para 108). Factors indicating that erasure is appropriate include offences involving violence (para 109g) and “persistent lack of insight into the seriousness of [the doctor’s] actions or the consequences” (para 109j).

24. More generally, a person made subject to a suspended sentence of imprisonment will not necessarily receive a sanction of suspension from the register rather than erasure. A suspended sentence of imprisonment marks serious criminality in that it cannot be imposed unless the offence reaches the custody threshold. GMC Policy: Good Medical Practice

25. The GMC has produced guidance for doctors called “Good Medical Practice” (“GMP”). The version in force at the material time in this case states at para 1: “Patients need good doctors. Good doctors… act with integrity and within the law.”

26. The section of GMP entitled “Act with honesty and integrity” states at para 65: “You must make sure that your conduct justifies your patients’ trust in you and the public’s trust in the profession.” The facts

27. I turn to the facts. The appellant graduated in medicine in Lahore, Pakistan in 2017. From January to August 2019, he worked as a Government Medical Officer in Punjab. In August 2019, he came to the United Kingdom and began work as a Trust Grade Foundation Year 2 doctor at a hospital in Grimsby. After completing his ordinary training in Carmarthen, he was due to start higher training in Gastroenterology when, on 22 December 2023, he was charged with controlling or coercive behaviour. The material allegations which underlay the charge were expressed as follows in the papers before the Crown Court: “i) On a day between 30th day of April 2021 and the 1st day of June 2021, during an argument, [the appellant] kicked [his wife] to her back with his right foot despite being aware that she was pregnant, causing her to fall to the floor on her stomach. ii) On a day between the 30th day of September 2021 and the 1st day of November 2021, following an ante-natal scan at Glangwili Hospital, he became angry and aggressive and punched her twice to her back and then punched her to the area where an injection had just been administered. iii) On a day between the 31st day of October 2021 and the 1st day of December 2021, following a verbal argument regarding relatives he assaulted her by pushing her to the floor and dragging her into the living room and then ordered her to leave the address so that he could cool down. iv) On the 23rd day of December 2021, whilst sitting in a parked car at Glangwili Hospital, he assaulted her by grabbing her hair and hitting her head against the inside of a car window. v) On the 25th day of December 2021, whilst in a car at Glangwili Hospital, he assaulted her by pulling her hair and then hitting her head against the car window. vi) On a day between 30th day of September 2022 and the 1st day of November 2022, whilst staying in the Premier Inn, Manchester, with the children, he assaulted her by punching her to the face on her eye. He also assaulted her by hitting her with a belt, causing her to have to leave the hotel room with the children. vii) On the 23rd day of June 2023, he assaulted her by slapping her to the face four times, after she failed to take a photograph for his visa to his satisfaction. He also kicked her to her back with his right foot. viii) On the 26th day of June 2023, he went to strike her. When she threatened to call the police, he became even more angry and he assaulted her by grabbing her to her throat, pushing her against the wall and slapping her to the right side of her face.”

28. On 28 December 2023, the appellant made a self-referral to the GMC in relation to the charge. Following a trial at Swansea Crown Court in July 2024, he was found guilty by the jury. On 3 September 2024, he was sentenced by HHJ Catherine Richards to 22 months’ imprisonment suspended for a period of 18 months. The judge imposed a rehabilitation activity requirement of 20 days together with 250 hours of unpaid work. She made a restraining order prohibiting the appellant from contacting his wife for a period of two years.

29. The judge sentenced the appellant on the basis of the eight allegations that I have set out above (erroneously described as seven allegations in her sentencing remarks). She found that the seriousness of the offence was aggravated by two important factors. First, on some occasions the appellant’s children were present when he was abusing his wife. Secondly, he had put pressure on his wife not to seek help by suggesting that the children would be taken from her if she did so. These factors cast light on the seriousness of the appellant’s conduct. Proceedings before the MPT

30. The allegation before the MPT was that the appellant’s fitness to practise was impaired by reason of his conviction. The appellant admitted the conviction. He denied that his fitness to practise was impaired, so that the Tribunal was required to reach a conclusion on that question.

31. In determining the question of impairment, the MPT considered documents from the criminal trial and sentencing process; a letter from the appellant’s counsellor, Mr Dale Williamson; and character references. The appellant provided a witness statement (dated 29 January 2025) and gave oral evidence.

32. In its impairment decision dated 12 March 2025, the Tribunal noted that the appellant accepted the fact of his conviction but denied the allegations underlying the criminal charge. The Tribunal described the appellant’s denial of violence perpetrated against his wife in the following terms: “76. Dr Haroon recalled being in conflict with his ex-wife between October 2021 and June 2023, but did not accept that it resulted in violence. For two of the eight incidents Dr Haroon accepted that he and his ex-wife were in conflict and bickered but stated there was no violence involved. For six of the eight incidents, Dr Haroon did not give an account which even included verbal disagreement. He said that he believed all was well in his relationship.”

33. The MPT accepted that the appellant had the right to plead not guilty and went on to consider his behaviour and attitudes under a number of headings to which I now turn. Remorse

34. The Tribunal bore in mind that, in his witness statement, the appellant had expressed remorse and offered apologies to his children, his parents, his extended family, his employer, the wider medical profession, patients and the public. The Tribunal noted that his statement did not deal with the impact of his actions on his wife. He did not express remorse towards her or apologise to her in his witness statement.

35. As for the appellant’s oral evidence, the Tribunal’s impairment decision observed that, when cross-examined, the appellant had apologised for “missing out” his wife in his written statement. He had offered an oral apology in relation to the impact of his behaviour on his wife but did not apologise for the use of violence – which he denied. The Tribunal noted that the appellant “referred to his ex-wife as being very unkind in the things that she said” which he maintained were “not entirely factual.” The appellant regarded the conflict with his wife as no more than “a lot of bickering.” He mentioned the impact on his children as being the breakdown of the family unit and did not mention the impact of the children witnessing violence. The Tribunal concluded that, in all the circumstances, his remorse for his offending was limited. Insight

36. The Tribunal considered the appellant’s level of insight into his criminal conduct, holding as follows: “72. The Tribunal was mindful that, although it is a rare case that a doctor will have full insight where he has not accepted the conduct found proved against him, a denial is not an absolute bar to the development of insight. Dr Haroon accepts the gravity of such an offence, in so far as he understands the way in which society views his conduct as found proved. He has experienced damage to his reputation which is of regret to him, came close to an immediate custodial sentence and is still in the period of his suspended sentence benefitting from probation supervision. He may therefore be less likely to repeat such conduct…

77. In his oral evidence before the Tribunal, Dr Haroon stated that he understood that there were things that he could and should have done differently and stated that he now has coping strategies to deal with difficult situations that may arise within a relationship. However, there was no evidence that he had identified strategies to prevent conflict resulting in violence. The Tribunal heard Dr Haroon’s evidence regarding the knowledge and insight he gained in therapy. He was able to provide the Tribunal with evidence that he has a clear understanding that in a relationship violence is ‘never the answer’ even if ‘frustrated’ or one thinks it is justified. He referred to violence as the most negative form of expression. However, although his learning was based on an understanding that violence is never acceptable, he had not done any specific work personal to him on how to prevent conflict escalating to violence .

78. The Tribunal considered that Dr Haroon has insight into the gravity of violence in a relationship as something that is completely unacceptable. However, he has not demonstrated an understanding of a link between this insight and his actions in a relationship .

79. Dr Haroon does not currently demonstrate an understanding of how he allowed himself to act as he did towards his ex-wife which included violence , and what he would do differently to prevent his use of violence in the future. Dr Haroon has failed to demonstrate to the Tribunal what he would do if he found himself in similar circumstances…

81. The Tribunal noted that it was clear from his statement and oral evidence that Dr Haroon understands the broad areas of work that may help him to reduce his risk of violence. There is however no evidence that he has applied these generic ideas to his own particular behaviour nor explained his motivation(s) and trigger(s) . The Tribunal concluded that Dr Haroon only has limited insight ” (emphasis added). Risk of repetition

37. In considering the risk of repetition of criminal conduct, the Tribunal took into consideration that the pre-sentence report (“PSR”) in the criminal proceedings had assessed the likelihood of reoffending within the next two years as low. The PSR assessed the risk of serious harm to known adults as medium but that it might be high if the appellant were to enter into a new relationship. The risk to children was medium as the appellant’s children were present at the time of his offending behaviour.

38. The Tribunal took into consideration that the appellant had received a suspended rather than immediate sentence of imprisonment because the judge had found that there was a realistic prospect of rehabilitation, despite the appellant’s plea of not guilty. Noting that the appellant had (for reasons that were not his fault) completed only three of his 20 days’ rehabilitation activity requirement, such that work on reducing the risk of reoffending had not progressed, the Tribunal concluded that there remained a risk of repetition, particularly in light of the appellant’s “caveated and limited remorse towards his ex-wife and only limited insight.” Impairment

39. In concluding that the appellant’s fitness to practise was impaired, the Tribunal gave weight to a number of factors, including: i. The seriousness of the criminal offence which included acts of violence; ii. The fact that the appellant’s actions clearly brought the medical profession into disrepute; iii. The risk of repetition in the future; iv. The breach of fundamental tenets of the profession (reflected in paras 1 and 65 of GMP quoted above) that doctors should act within the law and retain the trust of patients and the public; v. The appellant’s lack of genuine remorse towards his wife; and vi. The appellant’s lack of insight into his offending behaviour.

40. The Tribunal considered that all of the three elements of the overarching objective were “engaged” and stated as follows: “101…The Tribunal considered that a member of the public who heard of the facts of this case would be appalled, and victims of domestic violence might be less inclined to report their own personal circumstances to a doctor as a trusted professional. The Tribunal considered that a finding of impairment is therefore required to protect, promote and maintain the health, safety and wellbeing of the public.

102. The Tribunal was of the view that the public would expect doctors not to commit such a serious criminal offence.

103. Dr Haroon's conduct falls so far short of what is expected from a doctor, and a finding of impairment is therefore required in order to maintain public confidence in the profession and to uphold proper professional standards and conduct.”

41. For these reasons, the Tribunal concluded that the appellant’s fitness to practise was impaired by reason of his conviction. Sanction

42. On 3 April 2025, following a further hearing at which the appellant continued to be represented by Counsel, the Tribunal gave its decision on sanction. It took into account the evidence received during the earlier stages of the proceedings and a “reflective statement” from the appellant dated 26 March 2025.

43. In its detailed written reasons, the Tribunal set out the parties’ submissions at length. It confirmed that it had had regard to: i. The statutory overarching objective and the three elements; ii. The principle of proportionality which involved weighing the appellant’s interests against the interests of the public; iii. That the purpose of a sanction was not punitive; iv. The need to apply the least restrictive sanction necessary by considering the least serious of the available sanctions first before moving to consider more serious sanctions; v. The need to consider aggravating and mitigating factors; and vi. The relevant parts of the Guidance, some of which was directly quoted in the Tribunal’s decision.

44. The Tribunal considered that there were a number of aggravating factors, as follows: i. The appellant had only limited insight into his actions; ii. Some of the incidents occurred in the presence of children; iii. A number of incidents occurred while his wife was pregnant or had just given birth; iv. The appellant had tried to put pressure on his wife not to seek assistance; and v. His conduct was repeated over a two-year period.

45. As regards mitigating factors, the Tribunal held: “42. Dr Haroon has had no previous fitness to practise history and no previous criminal convictions. There has also been no indication of any further concern in these regards.

43. The Tribunal acknowledged the testimonials provided in support of Dr Haroon. However, given the behaviour underlying the conviction, these testimonials were given minimal weight in the Tribunal’s consideration of the appropriate sanction to impose.

44. The Tribunal has taken into account the reflective statement provided by Dr Haroon and notes the further reflections, which do not materially change or advance the Tribunal’s findings at the impairment stage in relation to remorse, insight and remediation.”

46. In accordance with the Guidance, the Tribunal then considered the various possible outcomes in ascending order of seriousness. It determined that neither taking no action nor imposing conditions of registration would be appropriate. It is not in dispute that these less serious sanctions would not mark the seriousness of the appellant’s impairment.

47. As regards a more serious sanction, the Tribunal considered the guidance on suspension. It rejected the imposition of a suspension for the following reasons: “54. The Tribunal considered that it has no evidence before it as to whether or not remediation may be successful, as Dr Haroon continues to deny the offence and maintains his innocence... [T]he Tribunal has already determined that there are some factors which mean that Dr Haroon may be less likely to repeat such conduct, however, there remains a risk of repetition… [T]he Tribunal considered that Dr Haroon's conviction is fundamentally incompatible with continued registration.

55. The Tribunal was mindful of the impact of erasure on Dr Haroon. It noted the submissions of [Counsel for Dr Haroon] that a finding of erasure may impact Dr Haroon’s future medical career and his immigration status. The Tribunal had regard to the possible related impact that this could have on his family relationships. Nonetheless, the public interest outweighs Dr Haroon’s interest in this regard, in circumstances where: • there is a conviction for a serious criminal offence which has serious aggravating factors, particularly for a registered medical practitioner; • the Tribunal has found that his conduct is fundamentally incompatible with continued registration.

56. Therefore, the Tribunal concluded that a period of suspension would not be appropriate to sufficiently uphold the overarching objective.”

48. The Tribunal determined that the only appropriate sanction was one of erasure and held: “61. The Tribunal has found that Dr Haroon’s conviction is a serious breach of GMP and breached fundamental tenets of the medical profession. Members of the public and members of the profession would find the conduct deplorable and expect that the sanction would reflect the gravity of the offence.

62. In all the circumstances, the Tribunal determined that a finding of erasure is essential to protect and promote the health, safety and wellbeing of the public, promote and maintain public confidence in the medical profession and to promote and maintain proper professional standards and conduct for members of the profession.

63. Therefore, the Tribunal determined to erase Dr Haroon’s name from the Medical Register.” Appellant’s overarching submissions

49. In his written and oral submissions, the appellant submits overall that the decision to impose erasure was wrong and that the appropriate sanction was suspension from the register. In support of this overall contention, he makes two overarching submissions. I shall deal with these two submissions in turn. The approach of the Guidance to violent offences

50. Firstly, the appellant submits that the Guidance neither states nor implies that offences of violence should lead to erasure. He accepts that erasure may be imposed where this is the only means of protecting the public (Guidance, para 107) but submits that nothing emerges from the Guidance to suggest that, in cases involving violence, public protection will invariably outweigh the extremely serious consequences of erasure which may mean that a person never works as a doctor again.

51. In support of this submission, the appellant points out that an offence of violence is one of a number of factors listed at para 109 of the Guidance that “ may indicate” (emphasis added) that erasure is appropriate, leaving a wide discretion to the MPT to impose a lesser sanction. He emphasises para 119 of the Guidance which states that, as a general principle, a doctor who has been convicted of a serious criminal offence should not be permitted to resume unrestricted practice until they have completed their sentence. He submits that this statement of general principle would not make sense if erasure were the invariable sanction in cases of serious criminal convictions. He directs the court’s attention to passages in the Guidance which state that certain conduct is likely to result in erasure, namely dishonesty (Guidance, para 128); predatory behaviour (Guidance, para 148); and sexual misconduct (Guidance para 150). He submits that there is no such steer to tribunals in relation to violence and that the absence of any such steer should have driven the MPT to be more cautious before imposing erasure.

52. In my judgment, the Guidance is a practical document intended to be used by tribunals for the purpose of ensuring proportionate and consistent decision-making in the sphere of regulatory sanctions. It does not need to be exhaustive and cannot capture all scenarios that the MPT must adjudicate upon. The Guidance expressly indicates that offences of violence may lead to erasure which is in my judgment a sufficient steer for the purposes of the present case.

53. I reject the proposition that, upon a fair reading, the Guidance establishes a hierarchy of offences, with violence falling lower in the hierarchy than dishonesty, predatory behaviour and sexual misconduct. The Guidance facilitates a fact-sensitive approach to the imposition of sanctions. It was the duty of the MPT to consider the facts of the case and to conclude for itself whether erasure was appropriate in the appellant’s case. That is what the MPT did. MPT’s approach to insight and remorse

54. Secondly, the appellant submits that the MPT placed excessive weight on his denial of the allegations underlying his criminal conviction. He concedes that the MPT directed itself that, as a matter of principle, denial of the offence did not equate to lack of insight. However, he submits that, upon analysis, the MPT did not follow its self-direction and effectively treated his denial of the offence as decisively demonstrating a lack of insight.

55. Mr Anderson submits that the MPT’s impairment and sanction decisions were well-reasoned. He submits that the MPT did not fall into the sort of error posited by the appellant. He emphasises that the appellant’s attitude to the conduct underlying the criminal conviction was properly to be taken into account when weighing up insight: any assessment of ongoing risk must pay close attention to a doctor’s attitude to what he or she has done ( Sayer , para 25, above).

56. I agree with Mr Anderson. As I have set out above, the MPT expressly accepted at para 72 of its impairment decision that a denial of wrongdoing is not an absolute bar to the development of insight. It accepted that the appellant had insight into the gravity of the offence of which he had been convicted in so far as he understood the way in which society views his conduct as found proved. As set out above, the Tribunal accepted in para 77 of its impairment decision that the appellant understood that “there were things that he could and should have done differently.” On this basis, the Tribunal was willing to accept that he had some limited insight.

57. It cannot realistically be maintained that the Tribunal automatically treated the ongoing denial of criminal conduct as entailing that the appellant lacked insight. The Tribunal properly considered the evidence before it and reached a conclusion on insight that was open to it. There are no grounds for suggesting that the MPT’s conclusion that the appellant had limited insight is wrong.

58. Furthermore, as Mr Anderson submits, the appellant in his written and oral submissions continues to demonstrate limited insight. He says in his skeleton argument: “Where violence has always been denied altogether, what can still be agreed on is that, at the very least, it was not disproportionate or mindless abuse leading to significant bodily harm.”

59. Even in a case where violence is denied, this description of the underlying allegations is hard to reconcile with insight into the seriousness of (for example) kicking a pregnant woman in the back, causing her to fall on her stomach; or with hitting someone on the head against a car window; or with hitting someone with a belt (to mention just three of the underlying allegations).

60. The appellant’s skeleton argument describes his criminal conviction as “based on concerns raised by a single individual.” Even if the appellant disagrees with the verdict of the jury, this description fails to demonstrate any appreciation of the seriousness and number of the events underlying the criminal conviction and their considerable timespan. I would agree with the MPT that the appellant’s insight is limited. He was properly sanctioned on that basis.

61. Against this background, I turn to the grounds of appeal Ground 1: Failure to balance aggravating and mitigating factors appropriately

62. The appellant submits that, upon reading the sanction decision as a whole, the MPT failed to give proper weight to what he maintains are strong mitigating factors. He submits that the following factors ought to have been given greater weight: i. Remediation : The appellant submits that he has taken steps to remediate his impairment and has at all times been willing to take further steps. He has shown remorse in relation to those facts that he accepts. He has shown insight to the extent possible when he does not accept the allegations against him. Nothing more can be expected of him. ii. Character and career : He is of previous good character. All the evidence before the MPT showed that he has had a good medical career in Pakistan and in the United Kingdom. His career progression is well-documented and his latest appraisal document (“multi-source feedback”) demonstrates success in his training. He has produced testimonials which demonstrate his competence and ability as a doctor. He is dedicated to his profession which is very important to him. iii. Compliance : He complied with all police, court and GMC procedures.

63. The appellant submits that there are no aggravating factors and that the conduct of which he was accused marked a serious but remediable departure from GMP, such that erasure was a disproportionate sanction.

64. Mr Anderson submits that Ground 1 has no merit. He submits that the MPT had regard to both the aggravating and mitigating factors, which were properly balanced.

65. It is plain that the appellant disagrees with the way in which the MPT has approached aggravating and mitigating factors but that does not mean that the MPT was wrong or that this court must or should intervene. The MPT was right to say that the seriousness of his impairment was aggravated by the various factors which I have set out earlier in this judgment. The appellant is wrong to discount them. The MPT was entitled to conclude that the aggravating factors should carry weight. Its decision was clear and well-structured.

66. There is no merit to the appellant’s submission that the MPT failed to appreciate that mitigating factors may carry more weight in cases concerned with public confidence in the profession than in cases raising patient safety (Guidance para 24). The MPT’s approach to mitigating factors in this serious case, and the balance that it struck, cannot be impeached.

67. For these reasons, Ground 1 does not succeed. Ground 2: Failure to apply the Guidance and precedents correctly

68. The appellant submits that the MPT elevated the importance of public perception of the alleged conduct at the expense of a proper analysis of the prospects of remediation. He submits that the centrality of public perception to the MPT’s sanction decision was “a violation of both guidance and precedents.” By precedents, the appellant is referring to other cases that have come before the courts.

69. As I have indicated, this Ground relates both to the application of the Guidance and to the effect of case law. It is convenient to consider the appellant’s submissions about the case law before turning to his submissions on the Guidance and then to his more general submissions on public perception. Other cases

70. The appellant refers to a number of cases which (he submits) demonstrate on their facts and in their outcomes that the MPT in the present case took an erroneous approach towards whether suspension, rather than erasure, was appropriate: Khan v General Pharmaceutical Council (Scotland) [2016] UKSC 64 , [2017] 1 W.L.R. 169 , paras 12-18 and 36-41; Giele v GMC [2005] EWHC 2143 (Admin) , [2006] 1 W.L.R. 942 , paras 15-18 and 21-23; Bijl v GMC [2001] UKPC 42 , (2002) 65 B.M.L.R. 10, paras 13-15.

71. It is not fruitful to compare the facts of one case with another. The central question is not what happened in other cases on other facts but whether the MPT has reached a wrong decision on the facts of this case. As the appellant accepts, this central question is essentially to be resolved by applying the Guidance to the facts of this case. Guidance

72. In general, the MPT applied the Guidance properly and fairly, but two issues arise. First, Mr Anderson accepts that the MPT was wrong to apply para 148 of the Guidance which states that more serious action, such as erasure, is likely to be appropriate where a doctor has abused their position or where the conduct “constitutes a criminal offence.” In context, the reference to “a criminal offence” is to an offence involving predatory behaviour and not to offending more generally. It was an error for the MPT to have considered that para 148 applies to the appellant’s case. Nevertheless, the MPT was entitled to emphasise the seriousness of the appellant’s offending as a factor tending towards erasure, and its reference to para 148 is immaterial.

73. Secondly, the MPT stated that the appellant’s conduct amounted to a particularly serious, deliberate departure from the principles set out in GMP, namely the principles that (i) doctors must act within the law (para 1 of GMP) and (ii) doctors must make sure that their conduct justifies patients’ trust in them and the public’s trust in the profession (para 65 of GMP). In context, the latter principle appears to relate to trustworthiness in the sense of honesty and integrity, rather than saying anything about violence. However, any slip by the MPT about the effect of para 65 is trivial. There is no need to spell out in guidance that doctors who commit violent crimes will lose the trust of patients and the public. Any error about the effect of para 65 of the Guidance in this regard is immaterial.

74. Other than these two immaterial errors, I agree with Mr Anderson that the MPT applied the correct, escalating approach as set out in the Guidance and that it directed itself properly about insight in circumstances where the offence was denied. The MPT’s decision-making does not reveal any material error of approach. Public perception

75. The MPT was rightly concerned with public confidence (which is the correct term – rather than public perception). It was held in Bijl (at para 13) that “public confidence in the profession… should not be carried to the extent of feeling it necessary to sacrifice the career of an otherwise competent and useful doctor who presents no danger to the public in order to satisfy a demand for blame and punishment.” It is unrealistic to contend that the appellant’s career has been sacrificed to satisfy a demand for blame and punishment.

76. Nor can it be said that the MPT was unduly concerned with public confidence at the expense of the appellant’s career. As emphasised in Ibrahim v GMC [2022] EWHC 2936 (Admin) , paras 27-30, the Guidance states at para 56 that conduct in a doctor’s personal life may lead to a serious sanction on grounds of public confidence when it relates (among other things) to misconduct involving violence.

77. By way of cogent example of how public confidence may be damaged, the Tribunal found that permitting the appellant to remain registered as a doctor would convey to the victims of spousal abuse that there might be risks in reporting their own personal circumstances to a doctor as a trusted professional (see para 40 above). In any event, the MPT found that all of the three elements of the overarching objective were engaged in the present case so that its conclusions as to sanction did not rest only on public confidence. Ground 2 fails. Ground 3: Error in the determination of sanction

78. Finally, I turn to the appellant’s overall contention that the MPT erred in its determination of sanction because erasure was neither necessary nor proportionate. Standing back, this ground of appeal fails for the following reasons. Seriousness of offending

79. The appellant was convicted of numerous incidents of violence against his wife. The starting point is that his conduct was serious. It was rendered all the more serious by the aggravating factors identified by the MPT. Insight and remediation

80. On the unimpeachable findings of the MPT, the appellant has limited insight into his wrongdoing. His limited insight is amply demonstrated by the fact that he blames his wife for the criminal proceedings, accusing her of making so many allegations that he found the criminal case “difficult and complex” (appellant’s skeleton argument) and felt that he had to defend himself in court rather than plead guilty (oral submissions).

81. The appellant’s denial of his offending is not in itself a ground for erasure but the practical effect is that his remediation work has been undertaken on the inadequate basis that he has not been violent to his wife. The appellant relied in particular on a letter from his counsellor, Mr Dale Williamson. The letter states that the appellant had undertaken seven counselling sessions designed to help him make “healthier” decisions. It states that: “Dr Haroon has used our sessions to explore in depth the emotions and personal experiences associated with the conviction, his understanding of the reasons behind the accusations, the impact of being found guilty, and the ongoing implications for his career. Through our work, Dr Haroon has made significant progress in developing effective strategies to manage conflict, stress and anxiety. Moreover, he has gained a deeper understanding of how his decisions and behaviours have contributed to his current circumstances. Dr Haroon has expressed a desire to continue counselling with me indefinitely to further support his mental wellbeing during the GMC investigation and continue exploring the origins of certain behaviours and tendencies, of which he has already developed a comprehensive understanding.”

82. The appellant criticises the MPT for refusing to give the letter any weight. However, as Mr Anderson submits, Mr Williamson’s letter is vague and does not begin to deal with remediation in the context of spousal abuse. The MPT was entitled to place no weight on it.

83. The appellant relies on his witness statement and reflective statement as the other principal sources of evidence of insight and remediation. Nothing that the appellant says in these documents can possibly undermine the findings of the MPT that he had not achieved the level of remediation that would be compatible with continued registration.

84. When asked in cross-examination before the MPT about how the public would perceive the effect of his actions on his wife, he referred primarily to the impact on his own reputation and to all the suffering he had experienced, rather than to the impact on his wife. As Mr Anderson emphasises, his evidence to the MPT damaged rather than enhanced his case that his remediation has been effective.

85. The appellant told the Tribunal, and has told this court, that he wishes to undertake further remedial work. However, the MPT was not bound to await the outcome of any further work before reaching a decision on sanction. In any event, the MPT was not requested to do so.

86. These various factors amply justify the MPT’s conclusion that there remained a risk that the appellant would repeat the sort of behaviour that underlay his criminal conviction. The MPT was not wrong to conclude that the appellant’s level of impairment was fundamentally incompatible with continued registration, so that suspension would not have been a sufficient sanction (Guidance, para 92). Applying the test in Sastry , the sanction imposed was appropriate and necessary in the public interest. It was not excessive or disproportionate. Ground 3 is dismissed. Conclusion

87. For these reasons, the grounds of appeal fail. There are no grounds for this court to interfere with the sanction of erasure. The appeal is dismissed.