Dr Sarah Alam v General Medical Council

HHJ JARMAN KC: Introduction

1. Dr Alam appeals under section 40 of the Medical Act 1983 against findings by the Medical Practitioners Tribunal in its determination dated 8 April 2025 that she had been dishonest in making retrospective entries over the Easter weekend in 2018 in respect of 14 patients at the general practitioners’ practice in Blackburn where she was then a partner. The entries related to whether patients with chronic disease had been invited to attend an annual review. The tribunal found that accordingly Dr Alam’s fitness to practice was impaired and suspended her from practice for three months.

2. There are two grounds of appeal. The first is the Tribunal failed to review the overall consistency of the findings of honesty and dishonesty, which are logically incoherent. The second is that the Tribunal erred in the proper application of the burden of proof, by finding dishonesty based on an absence of evidence of dishonesty. Each of those are disputed by the respondent (GMC), which further submits that this court as an appellate court by way of rehearing should not interfere with the findings of fact of the Tribunal which is an expert tribunal and which saw and heard witnesses.

3. The entries found to have been dishonest related to a scheme for remuneration to the practice under the Quality Outcomes Framework (QOF) based on the annual number of annual reviews carried out by the practice. However, the scheme also recognises that some patients do not respond or fail to attend for review so also rewards the practice for patients who have been invited to review three times but still have not attended. Background

4. Dr Alam completed her training in 2014 and joined the practice in the same year. The following year she was made a partner. At that time data for the QOF scheme was collated and submitted by the practice manager and the senior practice nurse, referred to by the Tribunal as Ms H and Ms G respectively. However in September 2017 Ms G went on sick leave. In December 2017 Ms H left the practice, and it became clear that her replacement had little knowledge or experience of the QOF scheme. The deadline for 2017-8 data to be submitted under the scheme was the end of March 2018. As that approached, Dr Alam took the view that although she lacked experience of the scheme, she was the only partner who could take on the role. Her senior partner was winding down for retirement and she was the next most senior partner. She had some freelance assistance from Ms H.

5. Ms G returned to work in February 2018. She sent an email that month saying that she had noted that clinicians were ignoring alerts to invite patients with chronic disease for review. She accepted that time for appointments was tight but said that not much time was needed to follow simple steps. Dr Alam forwarded this to Ms E, the senior receptionist at the time, asking her to forward it to reception and emphasising the need to contact patients to book reviews and to code invites “systematically and opportunistically.” The Tribunal accepted the issue of what it termed recalls and codes was a live issue in the practice in early 2018 and that members of reception staff were involved in booking reviews.

6. On 29 March 2028 Ms H told Dr Alam that there remained a large number of patients who potentially had been given three invites which had not been recorded. At this point Dr Alam herself was on sick leave following an operation but worked over the weekend, examining thousands of entries on the notes of patients to find which of those with chronic disease had contact with a clinician or a member of staff when an oral invite to a review might have been given but not recorded. This laborious work went on into the small hours of the morning. The Tribunal’s determination

7. The hearing before the Tribunal took six days. Dr Alam gave evidence across days three and four and other witnesses from the practice gave written and oral evidence. The Tribunal also had the relevant patient notes. The Tribunal comprised a legally qualified chair, a lay member and a registrant member, and spent 15 days deliberating on the facts. On the day the determination was due to be delivered, the parties were told it would not be delivered before 4pm, and in the event it was delivered at about 5pm. Allegations of dishonesty were made in respect of 28 patients, involving some 84 entries on patient notes. Of those, the Tribunal found that entries on the notes of 14 patients were made retrospectively and dishonestly by Dr Alam over the Easter weekend.

8. Where Dr Alam’s evidence was that she herself had made an oral invitation to a patient, the Tribunal accepted that evidence even though there was no documentary corroboration. In making the entries in question, she assumed that where patients with chronic disease were seen by a clinician, by Ms G or by Ms R, an experienced health care assistant specialising in chronic disease, then an appropriate invitation would have been given orally although not recorded in the notes. The Tribunal also accepted Dr Alam’s evidence in respect of these entries.

9. The basis of the Tribunal’s finding of dishonest entries in respect of 14 patients related to where Dr Alam had assumed that patient contacts with other members of staff would have involved similar invites. She did this when Ms E invited patients for flu vaccinations, which were noted, but not invites for review. There were 10 instances of this. The Tribunal concluded at [115] that the email of 8 February 2018 “clearly evidenced that staff were not following pop up prompts and inviting patients in for reviews.” It is noteworthy that the Tribunal had earlier recorded at [47] that the email referred to clinicians rather than staff.

10. The Tribunal continued at [116]: “…given the position of Ms E and the difficult circumstances she and the other receptionists were working under at the time, and the email from Ms G, which had been copied to Dr Alam, clearly stating that the opportunity to issue invites was not being followed, the Tribunal found that it was not credible that Dr Alam would have genuinely believed that Ms E had issued that invite. There was a complete absence of anything on the face of the notes to suggest an invite had been made and whilst there may have been circumstances where Dr Alam would genuinely have had full confidence that a particular clinician would have invited a patient, the same could not be said for unhappy staff who had been asked to carry out more work. Dr Alam knew from the email of Ms G that staff were not following the instruction to offer invites and she could not have held a genuine belief that Ms E had made the invite entered in retrospect by her.”

11. Similar findings were made about conversations between patients and other members of staff where Dr Alam had retrospectively recorded a relevant invite, namely Ms S, a nurse who had recently joined the practice, Ms U a practice nurse, and Ms Z, a health care assistant. As to the former, the Tribunal at [167-8] said: “Given that Ms S had only recently joined the Practice and was having communication problems with Ms G, the Tribunal find that there is no basis upon which Dr Alam could, at that time, have genuinely believed that Ms S would have extended a verbal invite to Patient 24. She could have had no real knowledge of her working practice or commitment. In addition, although somewhat in contrast to this finding, the Tribunal noted that only two days earlier, Ms S had returned to the notes of Patient 23 to insert an invite that she had clearly forgotten to enter when she had seen the patient that morning. Whilst she did not record the entry as retrospective, the Tribunal considered this was evidence that had Ms S extended a chronic disease invite to Patient 24, it is likely that she would have recorded it in the notes and if she had by error forgotten to do so, she would have returned to the notes to enter it as she had done with Patient 23 just two days earlier. 168.The Tribunal did not accept that Dr Alam could have relied upon Ms S in the same way as she was able to with Ms G, because there had been no opportunity for that relationship, trust and knowledge to build up.”

12. In respect of Ms U, the Tribunal said this at [176]: “The Tribunal then went on to consider the consultation with Patient 25 on 9 October 2017, with Ms U. Dr Alam told the Tribunal that Ms U was an experienced nurse and was described in the staff list provided to the Tribunal as a long term locum practice nurse. The Tribunal was not provided with any further information about this nurse or what role she carried out in the Practice. The Tribunal noted that unlike the other practice nurses, Ms U was not copied into the emails from Ms G or Ms J about QOF reporting. Whilst the Tribunal accept that there were genuine steps taken to encourage staff to seize every opportunity to extend invites to patients for chronic disease reviews, it does not accept that just because staff have been told to follow that instruction it can be guaranteed that they will do so. During its deliberations the Tribunal has found occasions where, on the balance of probabilities it has been reasonable to find that Dr Alam was entitled to rely on some staff. The Tribunal has not made this finding lightly but has based its decision on the position held in the Practice, the employee’s connection to QOF reporting and the relationship that has been evidenced before the Tribunal. The Tribunal can find no such basis on which to find that Dr Alam could be confident that Ms U had issued the invite relied on. The Tribunal do not accept that there is evidence in the consultation record upon which this could be concluded by Dr Alam and consequently it finds that there is no basis upon which she could hold that belief. The entry in the later notes of 30 October 2017, simply records “review if needed”. In addition, the Tribunal note that at the beginning of October 2017, it was accepted by Dr Alam that there was not such a strong focus on staff making opportunistic appointments as this only became a priority in January 2018 when the March deadline was looming.”

13. As for Ms Z, the finding of the Tribunal was as follows at [228-230]: “228. On 26 January 2018 Ms Z, a Health Care Assistant, noted in the medical record: “Called to book an appt for diabetic bloods/son answered will ask father to call.”

229. The Tribunal also noted that the purpose of the telephone call was not for a chronic disease review, but to request the patient come in for a blood test. The Tribunal considered that on the face of the entry there is no evidence to indicate that the patient had been invited in for a review.

230. The Tribunal found that whilst Dr Alam may not have properly addressed her mind to what was recorded in respect of the consultation of 26 January 2018, she could not have held a genuine belief that a chronic disease review invite had been offered to this patient.”

14. Mr Colman, for Dr Alam, submitted in writing and orally, that the Tribunal found that an entry which Dr Alam made in respect of patient 41 was made without a genuine belief on her part in the correctness of the entry. That is what is recorded at [254] and [257]. However he also pointed to [287] where the finding in respect of the same entry was that it was an honest mistake. Mr Tankel, for the GMC, in his skeleton argument, maintained that there was no finding that this was an honest mistake, but when [287] was put to him in the course of his oral submissions, he had to concede that he could not support the finding of dishonesty in relation to this entry. Accordingly that finding is quashed. Mr Colman did not seek to draw an inference from this that other findings were suspect, but put it forward as an example of flawed reasoning. The statutory framework

15. Section 40 of the 1983 Act materially provides: “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 35D above giving a direction for … suspension … (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 MPTS 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 (or, in Scotland, expenses) as it thinks fit.”

16. The relevant rules for such an appeal are set out in Civil Procedure Rule 52.21 (3) and (4): “(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. (4) The appeal court may draw any inference of fact which it considers justified on the evidence.” Legal principles

17. I was referred to several authorities on the proper approach of the Tribunal as to the findings of dishonesty and the proper approach of this court on appeal. Mr Colman accepts that as the appeal seeks to challenge findings of fact by the Tribunal, namely the findings of dishonesty on the part of Dr Alam, there is a need for this court to follow well established principles.

18. Clarke LJ in said: at [15-16] Assicurazioni Generali SpA v Arab Insurance Group (Practice Note) [2003] 1 WLR 577 "'15. In appeals against conclusions of primary fact the approach of an appellate court will depend upon the weight to be attached to the findings of the judge and that weight will depend upon the extent to which, as the trial judge, the judge has an advantage over the appellate court; the greater that advantage the more reluctant the appellate court should be to interfere. As I see it, that was the approach of the Court of Appeal on a "rehearing" under the Rules of the Supreme Court and should be its approach on a "review" under the Civil Procedure Rules 1998 .

16. Some conclusions of fact are, however, not conclusions of primary fact of the kind to which I have just referred. They involve an assessment of a number of different factors which have to be weighed against each other. This is sometimes called an evaluation of the facts and is often a matter of degree upon which different judges can legitimately differ. Such cases may be closely analogous to the exercise of a discretion and, in my opinion, appellate courts should approach them in a similar way.'"

19. At [67], Clarke LJ continued: “67. That general caution applies with particular force in the case of a specialist adjudicative body, such as the Tribunal in the present case, which (depending on the matter in issue) usually has greater experience in the field in which it operates than the courts: see the Smech case [2016] JPL 677, para 30 ; Khan v General Pharmaceutical Council ; [2017] 1 WLR 169 , para 36 Meadow's case ; and [2007] QB 462 , para 197 Raschid v General Medical Council . An appeal court should only interfere with such an evaluative decision if (1) there was an error of principle in carrying out the evaluation, or (2) for any other reason, the evaluation was wrong, that is to say it was an evaluative decision which fell outside the bounds of what the adjudicative body could properly and reasonably decide: the [2007] 1 WLR 1460 , paras 18–20 Biogen case ; [1997] RPC 1 , para 45 Todd v Adams and Chope [2002] 2 All ER (Comm) 97, para 129 ; Designers Guild Ltd v Russell Williams (Textiles) Ltd (trading as Washington DC) ; [2000] 1 WLR 2416 , para 129 Buchanan v Alba Diagnostics Ltd . As the authorities show, the addition of 'plainly' or 'clearly' to the word 'wrong' adds nothing in this context.” [2004] RPC 34 , para 31

20. These passages were cited with approval more recently in the Court of Appeal in Sastry v GMC [2021] EWCA Civ 623 at [37].

21. In Southall v GMC [2010] EWCA Civ 407 , Leveson LJ said this at [47]: “ First, as a matter of general law, it is very well established that findings of primary fact, particularly if founded upon an assessment of the credibility of witnesses, are virtually unassailable (see Benmax v Austin Motor Co Ltd ); more recently, the test has been put that an appellant must establish that the fact-finder was plainly wrong (per Stuart-Smith LJ in [1955] AC 370 National Justice Cia Naviera SA v Prudential Assurance Co Ltd (The Ikarian Reefer) [1995] 1 Lloyd's Rep 455 at 458). Further, the court should only reverse a finding on the facts if it “can be shown that the findings … were sufficiently out of tune with the evidence to indicate with reasonable certainty that the evidence had been misread” (per Lord Hailsham of St Marylebone LC in Libman v General Medical Council at 221F more recently confirmed in [1972] AC 217 R(Campbell) v General Medical Council at [23] per Judge LJ). Finally, in [2005] 1 WLR 3488 Gupta v General Medical Council , Lord Rodger put the matter in this way (at [10] page 1697D): [2002] 1 WLR 1691 “In all such cases the appeal court readily acknowledges that the first instance body enjoys an advantage which the appeal court does not have, precisely because that body is in a better position to judge the credibility and reliability of the evidence given by the witnesses. In some appeals that advantage may not be significant since the witnesses' credibility and reliability are not in issue. But in many cases the advantage is very significant and the appeal court recognises that it should accordingly be slow to interfere with the decisions on matters of fact taken by the first instance body. This reluctance to interfere is not due to any lack of jurisdiction to do so. Rather, in exercising its full jurisdiction, the appeal court acknowledges that, if the first instance body has observed the witnesses and weighed their evidence, its decision on such matters is more likely to be correct than any decision of a court which cannot deploy those factors when assessing the position…”

22. As to the approach of the Tribunal to its determination, Morris J in Byrne v GMC [2021]EWHC 2237 (Admin) said this at [22]. “22. The standard of proof to be applied by the Tribunal and by this Court is the civil standard of balance of probabilities. As regards the position where the allegations, or the consequences for the person concerned, are particularly serious, the Appellant referred me to Casey at §16, suggesting that there is a need for a "heightened examination of the evidence". It was common ground that the correct approach is as set out in my judgment in O v Secretary of State for Education at §66. In that case, after referring to the relevant House of Lords and Supreme Court authorities ( Re B and Re S-B ) (which in turn referred to Re Doherty cited in Casey) , I summarised the position as follows: "(1) There is only one civil standard of proof in all civil cases, and that is proof that the fact in issue more probably occurred than not. (2) There is no heightened civil standard of proof in particular classes of case. In particular, it is not correct that the more serious the nature of the allegation made, the higher the standard of proof required. (3) The inherent probability or improbability of an event is a matter which can be taken into account when weighing the probabilities and in deciding whether the event occurred. Where an event is inherently improbable, it may take better evidence to persuade the judge that it has happened. This goes to the quality of evidence. (4) However it does not follow, as a rule of law, that the more serious the allegation, the less likely it is to have occurred. So whilst the court may take account of inherent probabilities, there is no logical or necessary connection between seriousness and probability. Thus, it is not the case that "the more serious the allegation the more cogent the evidence need to prove it".”

23. As for the extent to which good character and the inherent unlikelihood that a person of good character may act dishonestly, in Professional Standards Authority for Health and Social Care v General Dental Council and Danial [2024] EWHC 2610 (Admin) , Morris J said this at [26]: “26. I have been referred to Donkin v Law Society , [2007] EWHC 414 (Admin) Martin v SRA at §§51-54; [2020] EWHC 3525 (Admin) Khan v GMC at §92; and [2021] EWHC 374 (Admin) Sawati v GMC §§53 to 56. The position can be summarised as follows: [2022] EWHC 283 (Admin) (1) A disciplinary tribunal must take good character evidence into account in its assessment of credibility and propensity (the probability that the person has been guilty of misconduct). (2) However, a tribunal is not required slavishly in its reasons to give a self-direction to that effect. It is sufficient, where the matter is raised on appeal, if the appeal court is able to infer from all the material that the tribunal must have taken good character properly into account. (3) One of the principal circumstances where the tribunal will be able to make such an inference is where it has been given a clear legal direction on the issue of good character from the legal qualified chair or the legal adviser. (4) The significance of good character should not be overstated and should not detract from the primary focus on the evidence directly relevant to the wrongdoing. (5) Where it is clear that good character was taken into account, decisions as to the weight to be attached to it are pre-eminently a matter for the fact finder and ought not to be disturbed unless the decision is one which no reasonable tribunal could have reached.”

24. Recently in James v GMC [2025] EWHC 2049 (Admin) , Hill J said at [84-7]: “84. The Tribunal recorded the legal advice it had received that it could take into account the Appellant's good character both in considering whether it is more likely than not that he was telling the truth and whether he was likely to have behaved in the manner alleged; and noted that it had considered the testimonials about the Appellant: see [38] above.

85. However, there is no evidence that the Tribunal did consider these issues, or what weight they were afforded, when it assessed the evidence on paragraph 1a. There is no explanation in the determination as to what if any weight the Tribunal placed on this and why nonetheless it rejected his evidence.

86. This evidence of the Appellant's good character was particularly relevant given the circumstances of the case, in which the Appellant accepted that in his haste to ensure that Patient A remained safe with the mask placed securely over his mouth his hands may have made contact with the patient's body. Accordingly, the key issue for the Tribunal was not whether the Appellant' hands made contact with the patient (a slap) but rather whether his actions were no more than what was clinically necessary or an assault. His good character was directly relevant to that issue.

87. Again, these errors compounded those identified in Grounds 1-3.” Ground 1

25. With those principles firmly in mind, I now turn to consider each of the grounds. Mr Colman submits that the Tribunal, having meticulously considered each entry and each consultation, did not then take an overview to see whether each of the conclusions made sense as a whole. Almost all of the findings of the Tribunal in respect of the entries which Dr Alam made honestly were not made because of an insufficiency of evidence of dishonesty but were made on the positive basis that in those instances Dr Alam had a genuine belief that invitations had been issued and in most such cases found that they had been issued.

26. Mr Colman gave examples to show that the findings of the Tribunal meant that Dr Alam in making the entries over the Easter weekend of 2018 switched from honesty to dishonesty sometimes when there was only a minute or two between an entry that the Tribunal found to be honest and one which it found to be dishonest. That was the case in respect of patients 24 and 25. In respect of patients 33, 37, 40 and 44 the findings were such that Dr Alam switched from making an honest entry to then making a dishonest one then an honest one and then a dishonest one within the space of 40 minutes on 29 March 2018. Mr Colman submits that that did not accord with the case of either party and defies common sense. It was Dr Alam’s case that all entries were honest (although she accepted some were mistaken) and it was the case of the GMC that all entries which were left to the Tribunal to determine were dishonest as part of a dishonest process arising out of panic rather than with a view to financial gain.

27. Mr Colman further submitted that the failure of the Tribunal to take an overall view of its findings is demonstrated by its failure in its determination to make any reference to Dr Alam’s good character or that such character made it inherently unlikely that she would made dishonest entries. The only reference to “Testimonials” appeared in the list of documents. There were about a dozen of these including those from colleagues who had worked with her for up to 10 years, each of whom spoke in glowing terms about her honesty, competency and patient satisfaction. One example, which may suffice to demonstrate this, came from a professional colleague who included the following: “I have known Dr Alam for approximately the last 10 years as a trusted friend and colleague. Without exaggeration, and in all sincerity, I am struggling to think of a single other doctor I have ever been acquainted with who is as truly honest and moral in every aspect of their professional and personal conduct as Dr Alam.”

28. Mr Tankel accepts that the determination of the Tribunal did not involve the preference of one witness over another or factors going to credibility as such, but points out that as Dr Alam’s evidence was that all entries were made honestly and the Tribunal found some were made dishonestly, then in respect of the latter it must mean that the Tribunal did not accept her evidence on those entries.

29. That must be correct, but the essential basis of the difference as found by the Tribunal was the seniority and experience of the person whom Dr Alam concluded is likely to have made the invite. Where that person was a clinician or a senior member of staff, the Tribunal accepted that Dr Alam genuinely believed that that person would have extended an invite. Where however that person was a more junior or less experienced member of staff the Tribunal found that such belief was unlikely. That distinction does not sit easily with Ms G’s email in February 2018 that it was clinicians who were missing alerts or with the Tribunal’s finding that reception staff were involved in booking reviews.

30. I accept that this court should be very slow before interfering with the Tribunal’s finding of fact, but I do not accept Mr Tankel’s submission that in the particular circumstances of this case it cannot do so. Even if he is correct that the approach of the Tribunal was to evaluate all the evidence, rather than make inferences as Mr Colman puts it, it is open to this court to consider whether there was an error of principle in carrying out the evaluation process or whether the evaluation was wrong for some other reason.

31. In my judgment there were errors of principle in the Tribunal’s approach. The first is that it did not stand back from the minutiae and take an overview of the case on dishonesty given that it accepted that many entries were made honestly by Dr Alam. It may be that Mr Tankel is right to say that the case put forward by Mr Colman is more appropriately described as one of inherent improbability, rather than logical incoherence as Mr Colman puts it. It is conceivable that an honest person would, engaged in the task which Dr Alam was for the first time, reviewing 1000s of entries under time and other pressures over a weekend to meet the deadline, make some entries without a genuine belief in their accuracy. But this issue of probability was not considered by the Tribunal as it should have been.

32. The second error of principle was not to take into account Dr Alam’s good character or that that may make it unlikely that she would make some entries dishonestly. It is not in dispute that the chair gave a correct direction to the Tribunal that good character means that a doctor is perhaps less likely to have committed an alleged wrong and may be more capable of belief when it comes to credit. Mr Colman submitted to the Tribunal that when allegations of dishonesty are made the inherent improbability of doctors acting dishonestly must weigh in the balance. As he pithily put it, mistake is more likely than mischief. Following that, the chair expressed the hope that that was covered in the good character direction, to which Mr Colman replied “No.” The chair then replied that she used the words “less likely” rather than “inherent probability” and continued “but, yes, we agree with that approach.”

33. Even if that amounts to a correct direction on inherent improbability as Mr Tankel submits, which in my judgment is questionable, that does not explain why there is no reference at all to this in the Tribunal’s determination. In my judgment by far the most likely explanation is that in the intervening 15 days of deliberation the Tribunal became so immersed in detail that when it came to give its determination this factor was overlooked. I am unable to infer from all the circumstances of this particular case that it was properly taken into account.

34. Mr Tankel submits that there was no need to refer to this factor in the determination. He points to Hill J’s reference in James that there was no evidence that the Tribunal did consider these issues, or what weight they were afforded or why it rejected the doctor’s evidence. He relies on Hill J’s reference to such matters “compunding” other errors. I do not accept that submission. Hill J referred to these matters as errors, in circumstances where they were particularly relevant to the doctor’s explanation. In my judgement the unliklihood of someone with such a good character as Dr Alam making dishonest entries alongside honest ones is a particualary relevant factor and the Tribunal fell into error in not taking it into account.

35. In my judgment the unliklihood of Dr Alam switching in minutes from an honest frame of mind to a dishonest one and the unlikihood that someone of such good character and integrity should make dishonest entries rather than mistaken ones is so overwhelmingly strong that the findings of dishonesty cannot stand and must be quashed. Ground 1 is made out. Ground 2

36. As for ground 2, Mr Colman relies particularly on [176] of the determination and the reference to there being no basis on which it could find tht Dr Alam could be confident that that invite had been issued. He submits that the Tribunal had 15 days to make a careful decision in respect of each entry whereas Dr Alam had neither the time nor the capacity to go through such a meticulous process. He submits that the Tribunal found that Dr Alam had a genuine belief when it found a reasonable foundation in the evidence for such a belief and that this amounts to a reversal of the burden of proof. He also refers to [287] in relation to patient 41, where the Tribunal recorded that “on this occasion” it was prepared to give Dr Alam “the benefit of the doubt” (having previously found that that entry was dishonest, as indicated above).

37. Mr Tankel submits that the Tribunal’s findings of dishonesty were in relation to where the patient interaction was with a new or administrative member of staff and the Tribunal made a positive finding on the balance of probabilites that Dr Alam did not have genuine belief in the validity of the entry.

38. I accept, as Mr Tankel also submits, that the determination must be read fairly as a whole. Nevertheless, the indications relied upon by Mr Colman are concerning on such a fundimental principle as the burden of proof. It was not a question of whether Dr Alam could be “confident” that the invite had been issued. It was a question of whether she genuinely believed that it had. Nor was it a question whether it could be “guaranteed” that staff had followed instructions. Again it was a question of whether Dr Alam in making the entries had a genuine belief that they had. The absence of such a belief was for the GMC to prove on the balance of probabilites. The reference to giving her the benefit of the doubt “on this occasion” strongly suggests that on other occasions when there was doubt, such benefit was not given. In my judgment that would be to reverse the burden of proof. Conclusions

39. My findings in relation to ground 1 are sufficient to justify the quashing of the findings of dishonesty and the consequent findings of impairment and suspension. It is not therefore strictly necesary to determine ground 2. Were it necessary, I would accept the submissions of Mr Colman.

40. Counsel helpfully agreed that any outstanding consequential matters can be dealt with by written submissions. A draft order, agreed as far as possible, should be filed, together with any such submissions, within 14 days of hand down of this judgment.