Tribunal decisions

The decision

IAC-AH-CO-V1

Upper Tribunal
(Immigration and Asylum Chamber) Appeal Number: PA/07581/2019

THE IMMIGRATION ACTS

Heard at Field House
Decision & Reasons Promulgated
On the 6 June 2022
On the 20 June 2022

Before

UPPER TRIBUNAL JUDGE BLUM

EKA
(ANONYMITY DIRECTION MADE)
Appellant
and

THE SECRETARY OF STATE FOR THE HOME DEPARTMENT
Respondent

Representation:

For the Appellant: Mr Ume-Ezeoke, Counsel, instructed by JDS Solicitors
For the Respondent: Mr T Lindsay, Senior Home Office Presenting Officer

DECISION AND REASONS
1. Pursuant to s.12(2)(b)(ii) of the Tribunals, Courts and Enforcement Act 2007 the Upper Tribunal remakes the decision of Judge of the First-tier Tribunal Hone who, in a decision promulgated on 29 December 2020, dismissed the appellant’s human rights (Article 3 ECHR) appeal (the appellant having disavowed any reliance on his protection and Article 8 ECHR claim) against the decision of the Secretary of State for the Home Department (the respondent) dated 22 July 2019 refusing his protection and human rights claim.
Appellant’s Background
2. The appellant is a citizen of Nigerian born on 22 August 1975. He entered the United Kingdom on 3 October 2013 as a Tier 4 student. His leave expired on 30 January 2015. He overstayed his visa. He applied for asylum on 30 April 2018. Central to the appellant’s protection claim was a diagnosis of HIV, Hepatitis B and C, Tuberculosis, Liver fibrosis, heart failure, and end stage renal failure (for which the appellant received haemodialysis three times a week). The appellant additionally claimed to be at risk of herdsmen in the area of Kagbu, in Nasarawa State, where he was born and where he claimed most of his family resided. The application was refused on 15 April 2019. The respondent reconsidered the decision and refused the protection and human rights claim on 22 July 2019.
First-tier Tribunal Decision
3. At the outset of the appeal before the First-tier Tribunal the appellant’s representative conceded that the only ground of appeal was that to remove the appellant from the UK would result in a breach of Article 3 ECHR on health grounds. The appellant did not pursue his protection claim or Article 8 ECHR claim.
4. Having set out the medical evidence Judge Hone accepted that the appellant had serious health conditions including end stage renal failure, heart failure and liver failure. The evidence indicated that the appellant was also HIV positive and had chronic Hepatitis B and C. The appellant’s treatment consisted of haemodialysis therapy three times a week which he would require for the rest of his life as the option of a transplant was not, at that stage, available to him because of his other medical conditions. The appellant was also on highly active anti-retroviral therapy for HIV.
5. Judge Hone found that the medical evidence, which was principally contained in an email from Dr Emma Salisbury, Consultant Nephrologist at Imperial College Healthcare NHS Trust, dated 29 October 2019, was not a report. The judge stated that in order to make findings that the Article 3 ECHR threshold was reached, he would need reports setting out the appellant’s current treatment, the effect on him of not receiving that treatment in the long and short term and a further report to say whether the treatment was not available in Nigeria including proof that the medication was not affordable. The judge concluded that there was insufficient evidence before him to determine the consequences to the appellant of a lack of treatment, and insufficient evidence to determine whether the appellant would be able to access the necessary treatment. The appeal was dismissed.

The challenge to the First-tier Tribunal’s decision
6. The grounds of appeal contended that the judge erred in his approach to the medical evidence when finding that he did not have before him evidence of the appellant’s treatment and prognosis and evidence of the consequences to the appellant of failing to receive treatment. It was further argued that the judge failed to take into account or give any weight to the evidence before the First-tier Tribunal of the lack of availability of treatment in Nigeria and the cost of dialysis for individuals with kidney failure and failed to make findings on that evidence. It was also submitted that the judge failed to take into account the evidence before him that the appellant would be unable to access treatment and that he would not be able to afford the necessary treatment. Finally, it was argued that the judge misdirected himself in law by failing to follow the guidance in AM(Zimbabwe) [2020] UKSC 17 by referring only “life expectancy” and failing to consider whether the appellant’s return would lead to a “serious rapid and irreversible decline in his state of health resulting in intense suffering”.
7. At the ‘error of law’ hearing the Presenting Officer conceded that the judge had erred in failing to assess the evidence before him and failing to make findings on that evidence, particularly in respect of the cost of treatment. The Presenting Officer did not attempt to defend the First-tier Tribunal judge’s decision.
8. In her ‘error of law’ decision promulgated on 3 December 2021 Upper Tribunal Judge Owens summarised the email of 29 October 2019 from Dr Salisbury:
i) The appellant’s medical condition was “severe”.
ii) He had serious and chronic health conditions including;
a) end stage renal failure (December 2017) in the context of late diagnosis HIV infection with viral load more than 3 million copies
b) Presumed chronic Hepatitis B infection diagnosed at the same time
c) Hepatitis C infection diagnosed at the same time - this relapsed on cessation of treatment in October 2019
d) Lung problems
e) Biventricular cardiac failure
f) Hepatomegaly presumed secondary to right sided heart failure and
g) rapidly progressive liver fibrosis as evidenced by serial fibroscans
iii) The appellant was receiving treatment both from Imperial College Healthcare Trust (for renal failure) and from Dr Angela Bailey at St Mary’s Hospital for HIV and heart problems.
iv) The appellant was on the following medication;
a) Highly active anti-retroviral drugs for HIV (co-trimoxazole, dolutgravir, emtricitabin, tenofovir)
b) Haemodialysis therapy for 4 hours, three times a week via right internal jugular tessio line at Hammersmith Hospital - Medication is (Neorecormon and alfacalcidol)
c) Sevelamer
d) Folic acid
e) Bisoprolol, ramipril, nifedipine
9. Dr Salisbury went on to deal with prognosis in a paragraph headed “prognosis”. She stated;
“Mr [K]’s kidneys will never recover so he will require dialysis for the rest of his life unless he were to receive a kidney”.
10. She then stated;
“although given his current blood borne viruses, liver disease and cardiac failure he is not medially fit for transplantation anyway.
11. She commented that the appellant was in “a difficult position” and faced “a lifetime” of medical treatment.
12. Judge Owens set out the approach by the First-tier Tribunal to this evidence and then concluded, contrary to the findings of the First-tier Tribunal, that the medical evidence, the contents of which had been accepted by Judge Hone, showed that the appellant was manifestly a very sick man whose condition was severe, that he required haemodialysis for the rest of his life and that there was (at that stage) no prospect of improvement without this treatment. The medical evidence before the First-tier Tribunal set out the alternative treatment (i.e. a kidney transplant) but made it clear that this option was not (at that stage) open to the appellant because of his other medical conditions. Judge Owens found that the clear implication from this evidence was that that without dialysis the appellant would die. Judge Owen was satisfied on the evidence before her that the appellant’s medical condition was severe and very complex, that his kidneys would never recover and, without treatment, would fail.
13. Judge Owens observed that the Consultant focused on the prognosis for the end stage kidney failure only and did not deal with the prognosis in terms of the appellant’s other significant problems including his liver and cardiac problems commenting only that “he is in a difficult position”. This was after Dr Salisbury’s earlier note that the appellant’s liver fibrosis was rapidly progressive. Judge Owens found that the First-tier Tribunal erred by failing to grapple adequately with the medical evidence.
14. Judge Owens then considered the First-tier Tribunal’s assessment of the availability of treatment for kidney failure in Nigeria. The First-tier Tribunal judge did not consider that newspaper reports provided by the appellant helped him, and he stated that he would need a report or analysis to determine whether treatment was available to the appellant, and that no evidence has been presented that treatment was not affordable. The evidence before the First-tier Tribunal judge of the cost of treatment included a Guardian newspaper article, an article from “Nigerian Price” as well as the respondent’s own evidence summarised in the refusal letter. The Guardian newspaper evidence sets out the lack of availability of nephrologists in Nigeria and the difficulty of accessing dialysis. The article stated that about N400,000 was needed for monthly dialysis. The article referred to the fact that about 25 million Nigerians had kidney failure and that there was only one nephrologist per million of the population. The article referred to statistics prepared by the Nigerian Association of Nephrology and quoted a doctor as saying “However getting this dialysis becomes a problem due to the huge cost involved and lack of nephrologists. The cost of dialysis is about N30,000 per session and the patients need about 3 sessions per week which is almost N100,000 per week and N400,000 per month. Not many Nigerians can afford this, and the National Insurance scheme covers just three sections of the dialysis.” The article quoted from the immediate past president of the Nigerian Association of Nephrology, Dr Bamgboye, who said that dialysis centres were grossly inadequate and found mostly in urban areas.
15. A second article from “Nigerian Price” stated that the cost of dialysis varies from N20,00 to N30,000 per session which equated to anything from N80,000 to N120,000 per week depending on the number of sessions. The article confirmed that different clinics charge different amounts and some private hospitals charge N50,000 per session. Treatment was more expensive in some parts of Lagos and Abuja.
16. Judge Owens was satisfied that the First-tier Tribunal erred by failing to take into account this evidence and by failing to make findings on the cost of treatment. Further the First-tier Tribunal judge appeared to have completely overlooked the respondent’s own evidence from the Country Policy and Information Note: Medical and Healthcare Issues dated November 2018. Paragraph 96 of the refusal letter quoted evidence stating that “Chronic Kidney Disease treatment is not economically accessible”. It also quoted evidence that “Most of the rural population is too poor to pay for the service and even if they could afford the treatment, there is an absence of efficient transportation system to enable access”. The First-tier Tribunal judge did not refer to this evidence.
17. Judge Owens noted that the appellant’s representative argued in submissions that he would not be able to afford treatment. The First-tier Tribunal judge’s attention was drawn to the appellant’s evidence given in his asylum interview in respect of his financial and family circumstances in Nigeria. The appellant stated that he previously worked as a teacher earning N70,000 per month and that on this salary he would not be able to afford dialysis. He came from a family of smallholders in rural northern Nigeria in Nasarawa state. His father was deceased, and his mother was 100 years old. His remaining 3 siblings lived in his state. His family made sacrifices for him to receive an education and since he was the only member of his family to receive an education in the past, it was he who provided financial support to the remainder of his family. He describes them as subsistence farmers. One of his brothers-in-law was a teacher and another had a shop. His fiancée worked selling chickens to get by whilst she was looking for work. He ran out of money to complete his Masters in the UK and friends and family in Nigeria were not able to pay the remainder of the money. Throughout his interview he asserted that he was not able to afford medical treatment. He pointed not only to difficulties in accessing financial resources to pay for the treatment but the physical problems of travelling to access his treatment.
18. There was no indication that the First-tier Tribunal judge took into account this relevant evidence and no indication that the First-tier Tribunal judge considered what weight to give to it if any, or why if the judge felt it should be rejected, the reasons for doing so. Judge Owens stated that it was an error of law for a Tribunal to fail to take into consideration material evidence and resolve material issues. Judge Owens was satisfied that the First-tier Tribunal judge erred by failing to consider what evidence was before him, to engage with it and to make findings on what was available rather than demanding further expert reports. Manifestly an expert report would not be able to address the credibility of the appellant’s assertion that he was not able to afford the treatment in any event.
19. These errors were material because the issue of the cost of the treatment and the ability of the appellant to pay for the treatment were central to the appeal and had the judge engaged with the evidence and made the appropriate findings, he may have come to a different decision.
20. Judge Owens set aside the decision. As the contents of the medical report by Dr Salisbury were accepted by the First-tier Tribunal Judge Owens preserve her conclusions as findings. No other factual findings were preserved.
21. As there were insufficient findings of fact for Judge Owens to re-make the appeal without a further hearing, and, in particular, as there was a need for findings on whether the appellant could afford the treatment, and given the vintage of the original First-tier Tribunal hearing, Judge Owens was satisfied that the appeal should be re-made at the Upper Tribunal.
The re-making hearing
22. The appellant provided a further bundle for the remaking hearing that included a further witness statement from him dated 6 June 2022, a further letter from Dr Emma Salisbury dated 20 January 2022 setting out the background to the appellant’s medical conditions and his current medications, and a letter from Sara Ayres, Lead Nurse HIV at Imperial College Healthcare NHS Trust dated 24 January 2022. The same bundle included notices relating to the deaths of the appellant’s brother, [HNK], his sister [ARB], and his mother [ANK]. Also included was an email said to come from his brother [JK] sent on 10 November 2020. The remainder of the bundle included an article from “guardian.ng” dated 12 March 2018 headed “Addressing rising cases, high cost of treating chronic kidney disease”, an abstract of an article appearing in the African Journal Online headed “Cost evaluation of haemodialysis for end-stage renal disease patients: experience from Benin city, Nigeria” dating from 2013. The bundle also included newspaper articles from 2021 relating to security issues in Nasarawa state, and some photographs of a derelict building.
23. The respondent produced a bundle of documents that included a skeleton argument authored by Mr Clarke, Home Office Presenting Officer, dated 9 May 2022, copies of the appellant’s asylum screening interview, his substantive asylum interview, and the “Application Details” relating to his student entry clearance application made in 2013.
24. I recorded the oral evidence from the appellant, who gave his evidence in English, and the oral submissions made by Mr Ume-Ezeoke on behalf of the appellant and by Mr T Lindsay on behalf of the respondent. I have read and considered with care all the documents before me even if they are not specifically identified later in this decision. Both parties are aware of the evidence, both written and oral, that was before the Tribunal. This evidence is, in any event, a matter of record. I shall refer to this evidence only in so far as it is necessary for me to lawfully determine the appellant’s human rights appeal.
Legal framework
25. Article 3 ECHR stipulates”
No one shall be subjected to torture or to inhuman or degrading treatment or punishment.
26. Under section 6 of the Human Rights Act 1998 it is unlawful for a public authority to act in a way which is incompatible with a Convention right.
27. At [22] of AM (Zimbabwe) [2020] UKSC 17 (“AM-SC”) the Supreme Court set out the test established in Paposhvili v Belgium [2016] ECHRR 1113 at [183]
“The Court considers that the 'other very exceptional cases' within the meaning of the judgment in N v The United Kingdom (para 43) which may raise an issue under article 3 should be understood to refer to situations involving the removal of a seriously ill person in which substantial grounds have been shown for believing that he or she, although not at imminent risk of dying, would face a real risk, on account of the absence of appropriate treatment in the receiving country or the lack of access to such treatment, of being exposed to a serious, rapid and irreversible decline in his or her state of health resulting in intense suffering or to a significant reduction in life expectancy. The Court points out that these situations correspond to a high threshold for the application of article 3 of the Convention in cases concerning the removal of aliens suffering from serious illness."
28. The head notes in AM (Art 3; health cases) Zimbabwe [2022] UKUT 00131 (IAC) (“AM-UT)” read:
1. In Article 3 health cases two questions in relation to the initial threshold test emerge from the recent authorities of AM (Zimbabwe) v Secretary of State for the Home Department [2020] UKSC 17 and Savran v Denmark (application no. 57467/15):
(1) Has the person (P) discharged the burden of establishing that he or she is "a seriously ill person"?
(2) Has P adduced evidence "capable of demonstrating" that "substantial grounds have been shown for believing" that as "a seriously ill person", he or she "would face a real risk":
[i] "on account of the absence of appropriate treatment in the receiving country or the lack of access to such treatment,
[ii] of being exposed
[a] to a serious, rapid and irreversible decline in his or her state of health resulting in intense suffering, or
[b] to a significant reduction in life expectancy"?
2. The first question is relatively straightforward issue and will generally require clear and cogent medical evidence from treating physicians in the UK.
3. The second question is multi-layered. In relation to (2)[ii][a] above, it is insufficient for P to merely establish that his or her condition will worsen upon removal or that there would be serious and detrimental effects. What is required is "intense suffering". The nature and extent of the evidence that is necessary will depend on the particular facts of the case. Generally speaking, whilst medical experts based in the UK may be able to assist in this assessment, many cases are likely to turn on the availability of and access to treatment in the receiving state. Such evidence is more likely to be found in reports by reputable organisations and/or clinicians and/or country experts with contemporary knowledge of or expertise in medical treatment and related country conditions in the receiving state. Clinicians directly involved in providing relevant treatment and services in the country of return and with knowledge of treatment options in the public and private sectors, are likely to be particularly helpful.
4. It is only after the threshold test has been met and thus Article 3 is applicable, that the returning state's obligations summarised at [130] of Savran become of relevance – see [135] of Savran.
Findings of fact and conclusions
29. I have considered the preserved findings made by the First-tier Tribunal judge in respect of the content of Dr Salisbury’s email of 29 October 2019. Those findings must however now be considered in light of the most recent medical evidence.
30. The most recent letter from Dr Salisbury can be summarised as follows:
• The appellant presented with unheralded End Stage Kidney Disease in December 2017 in the context of late diagnosis of HIV infection with viral load “> 3 million copies”.
• “Presumed chronic, hepatitis B infection diagnosed at the same time. Viral load 170 million copies
• hepatitis C infection diagnosed at the same time. Has since completed eradication therapy. Granulomatous cervical lymphadenitis - presumed disseminated Mycobacterium tuberculosis infection. Treatment now complete.
• Mycobacterium avium infection. Treatment now complete.
• ECHO March 2018: severe left ventricular (LV) dysfunction with severe functional mitral regurgitation (MR) and tricuspid regurgitation.
• Cardiac MRI April 2019: considerable improvement with LV ejection fraction 52%. Moderate MR.
• Episode non-concordance with antiretroviral therapy August 2020. Admitted with CXR changes suspicious of PCP but subsequently failed to be more in keeping with inadequate fluid removal on HDx.
• Covid Jan 2022.
31. The background, as described above in the Consultant’s letter, is difficult for a layperson to understand. It is not clear from the letter as to the current status of the appellant’s hepatitis B infection. There is little to indicate in the letter that the appellant is receiving any medication for hepatitis B. The letter does indicate that treatment has been completed in respect of the hepatitis C infection, in respect of the pulmonary Mycobacterium avium infection, and in respect of the Granulomatous cervical lymphadenitis. Dr Salisbury set out the medication given to the appellant on dialysis, and the medication prescribed by the dialysis unit for him to take at home. Dr Salisbury also identified the medication prescribed by the HIV team. No understandable reference or prognosis is made in the letter in respect of the appellant’s liver fibrosis or his previous heart failure. It is not apparent that the medication received by the appellant relates to his liver fibrosis, his previous heart failure or hepatitis B.
32. In her summary Dr Salisbury states:
“Mr [K] will require haemodialysis lifelong and without it he would die. We would hope to achieve renal transplantation for him but in order to achieve that we need his viral loads to be maintained at undetectable levels which has proved challenging. He was cleared by cardiology for transplantation in August 2020 but then stopped taking his anti-retroviral medication. HIV viral load still detectable in August 2021.”
33. It is apparent from this letter that several of the conditions from which the appellant had suffered were treated. There appears to have been a “considerable improvement” in respect of the appellant’s cardiac problems, and in respect of the hepatitis C and his pulmonary Mycobacterium avium infection. It is also apparent that the appellant could have a kidney transplant if his viral loads were maintained at undetectable levels.
34. In her letter Ms Ayres, the Lead Nurse HIV, confirmed the appellant’s diagnosis and current medication (consistently with that of Dr Salisbury) and indicated that the appellant’s CD4 count was 157, and his viral load was 75. Ms Ayres commented, in respect of the appellant’s HIV, that he is “currently extremely immune-compromised and is at risk of opportunistic infections.” He previously had two AIDS defining illnesses which increased his mortality, even though they have been treated. Although he was currently managing to take his antiretrovirals, the appellant “…has not mounted a good immune response and so remains at on-going risk of further opportunism infections added to this is his chronic kidney disease, this adds to his continues [sic] risk of a premature death.” She noted that the appellant had to chronic conditions affecting his liver, which was said to affect his overall health and that he was at increased risk of further damage.
35. Ms Ayres stated that the appellant’s medical conditions were complex to manage from a medical perspective and that he has limited HIV medication options “… And should he be removed from the UK his life would severely shortened and an early death would be inevitable.” She then indicated that HIV medication needed to be taken at the same time daily and if this did not happen the appellant’s life would be severely shortened (although no details were provided as to how long this process would take). She also indicated that stress and anxiety could lead to missed doses. Ms Ayres then made a general comment that HIV remains a very stigmatising condition in the UK “and particularly in other nations and that accessing support and treatment remained very difficult and that it was vital that the appellant continued to be supported.” She stated:
“In summary this is a gentleman who is immunocompromised, with a complex historical and current health needs and we would support his application to remain in the UK.”
36. I have concerns with Ms Ayres evidence. She asserts that the appellant has limited HIV medication options but there is no assessment of the options that may be available him in Nigeria, either in respect of the same medications or alternative combinations of medications. Further, Ms Ayres asserts that the appellant’s removal from the UK would severely shorten his life and lead to an early death, a matter that she says is “inevitable”. It is not clear how this conclusion was reached. No reference is made to the possibility of the appellant obtaining similar or alternative HIV treatment in Nigeria or in respect of the provision of dialysis in Nigeria. Ms Ayres does not purport to have any knowledge of the medical facilities in Nigeria, either in respect of the treatment of HIV, or in respect of the appellant’s chronic kidney disease, or indeed in respect of any the other conditions from which he suffers. Her conclusion that “an early death would be inevitable” if the appellant was removed is insufficiently unreasoned.
37. Having considered the preserved findings made by the First-tier Tribunal judge in respect of the content of Dr Salisbury’s email of 29 October 2019, in conjunction with the more recent medical evidence specific to the appellant’s medical conditions, I am satisfied that he is a seriously ill person, with reference to headnote 1(1) of AM-UT. In his oral submissions Mr Lindsay “broadly accepted” that, if the appellant did not receive the appropriate treatment, there would be a real risk that he would be exposed to a serious, rapid and irreversible decline in his state of health resulting in intense suffering, or that he would be exposed to a significant reduction in life expectancy. Put another way, Mr Lindsay accepted that if the appellant’s current medical treatment ceased, the Paposhvili test would be met.
38. The issues that I need to determine relate to headnote 1(2) of AM-UT. Has the appellant adduced evidence capable of demonstrating that substantial grounds have been shown for believing that, as a seriously ill person, he would face a real risk of either a significant reduction in his life expectancy or of being exposed to a serious, rapid and irreversible decline in his state of health resulting in intense suffering, on account of an absence of appropriate treatment in Nigeria or the lack of access to such treatment. (My emphasis)
39. Mr Ume-Ezeoke relied on 2.5.2 of the CIN which indicated that, according to the European Journal of Pharmaceutical and Medical Research (EJPMR), the current system of drugs distribution in Nigeria is chaotic and that the most notable fallout was the unrestricted circulation of fake, substandard and adulterated pharmaceutical products. The EJPMR report also noted that figures from different sources showed that between 15% to 75% of total drug circulating in the country were fake. It also noted that poor coordination of medicines procurement and supply to public facilities led to shortage of medicines, which were very common in governmental hospitals particularly in primary healthcare facilities. Whilst I take this evidence into account it is general in nature and does not specifically refer to medication for the treatment of kidney disease or in respect of dialysis or HIV. In the particular sections of the CIN report dealing with dialysis and HIV there is no reference to patients dying or being made more ill by the provision of fake drugs. I note at 2.5.4 reference is made a 2019 paper which referred to the increased demand for private healthcare which predominantly catered from the middle-class cadre because of the high cost of accessing government specialist hospitals as well as the bureaucratic structure of general hospitals, and that private health provision had higher costs because of the availability of genuine drugs and the services rendered by private practitioners. At 2.6.4 it was noted that the situation had improved in terms of take drugs as a result of measures taken by Nigeria’s Agency for Food and drug Administration Control.
40. I have considered the evidence relating to the availability of treatment for the appellant’s end-stage kidney failure set out in the bundle of documents prepared for the First-tier Tribunal hearing. An article in a document from “leadership.ng” referred to proposed kidney and dialysis centres in Nasarawa State has been billed to take off “next year” (the document appears to have been downloaded on 10 June 2020) as the necessary structural work. I have already referred to the Guardian article and the article from Nigerian Price in paragraphs 14 and 15 above. I note the references to the “huge costs involved and lack of nephrologists” in Nigeria, and I take into account the reference in the Guardian article that three weekly sessions of dialysis would be almost a 100,000 naira, and that not many Nigerians could afford this, and that the National Health Insurance Scheme (NHIS) covers just three sections of the dialysis (although no further details of the NHIS scheme were provided). I also take into account the reference to there being about 160 nephrologists in the country. Although the Guardian article quotes Dr Bamgboye as stating that dialysis centres were “grossly inadequate”, no explanation or description was given as to the nature of the gross inadequacy, although he does say that the number of dialysis centres (about 149) and the number of dialysis machines (600) was “grossly inadequate”. The Nigerian Price article indicated that kidney dialysis has become common in Nigeria in recent times and that many health institutions now offer this procedure. The article indicated that weekly sessions could cost anything between 80,000 naira to 120,000 naira, with different clinics charging different amounts, and with some private hospitals charging over 50,000 naira per session. The cost of dialysis could be expected to be more expensive in some parts of Lagos and Abuja than another part of the country.
41. Another Guardian article, dated 12 March 2018, contained in the appellant’s new bundle of documents, referred to several studies that indicated that 17,000 new cases of chronic kidney disease were diagnosed yearly and only 2000 could afford dialysis treatment in Nigeria. A Consultant nephrologist at the Lagos University Teaching Hospital stated that one session of dialysis costs between 20,000 and 30,000 naira, and that kidney transplants cost about 6.5 million naira and above, and in some centres 10 million naira. The abstract from the African Journal Online, dating from 2013, indicated that average dialysis costs per month inclusive of procedures, investigations, medications and dialysis proper was about 292,950 naira for the first month for twice a week and 357,950 naira for the first month for three times a week dialysis. Average annual cost for three times a week dialysis was 2,760,450 naira. This was in contrast to the average annual salary of state civil service workers which ranged from 216,000 naira to 1,965,612 naira, and federal civil service workers 777,984 naira to 2,553,990 naira. The conclusion detailed in the Abstract was that the maintenance of haemodialysis as it was currently practised (in 2013) was extremely expensive and out of the financial reach of most Nigerians including employed ones.
42. The appellant did not provide any further background evidence in respect of the availability and cost of dialysis treatment in Nigeria, although Mr Ume-Ezeoke did rely on the background evidence provided by the respondent.
43. In the respondent’s skeleton argument it was noted that some of the dialysis medication prescribed to the appellant was available in Nigeria. The documentation upon which the appellant himself relies indicates that dialysis treatment is available, although it is expensive.
44. The respondent Country Information Note (CIN) “Nigeria: Medical treatment and healthcare”, version 4.0, December 2021 stated:
16.1.1 A MedCOI response from July 2019 stated:
‘There are haematologists… in most tertiary centres including: National Hospital, Abuja, Lagos University Teaching Hospital, University of Calabar Teaching Hospital, University of Portharcourt Teaching Hospital, Ahmadu Bello University, Zaria, University College hospital, Ibadan, Lagos state University Teaching Hospital, University of Ilorin Teaching Hospital, Ilorin, Nigeria with a few of them in private practice around the country such as Reddington Hospital and St Nicholas Hospital in Lagos. ‘Acute and chronic haemodialysis, peritoneal dialysis and surgical placement of shunt for hemodialysis are available in many of these centres. The investigations can be done in most hospitals. Kidney transplant has been carried out at Garki Hospital Abuja (Public/Private venture), St Nicholas Hospital in Lagos (Private) and Obafemi Awolowo University Teaching Hospital Complex, Ife (OAUTHC ) and Zenith Medical and Kidney Centre Abuja, in partnership with Fortis Hospital Banglore, India has conducted some successful Kidney Transplants in Nigeria.’
16.1.2 A MedCOI response from July 2020 stated:
‘There are nephrologists, urologists and internists working in the facilities like mentioned above [National Hospital – Abuja, Zenith Medical and Kidney Centre – Abuja, and in tertiary centres like in Lagos University Teaching Hospital and Lagos state University Teaching Hospital. And further these specialists are also working in private facilities such as Reddington Hospital and St Nicholas Hospital in Lagos. ‘Garki Hospital Abuja (Public/Private venture), St Nicholas Hospital in Lagos (Private) Obafemi Awolowo University Teaching Hospital Complex, Ife (Public) and Zenith Medical and Kidney Centre Abuja ( like mentioned above), in partnership with Fortis Hospital Banglore, India have conducted successful kidney transplants in Nigeria. Pre- and aftercare are available in these centres.’
16.1.3 The same MedCOI response also confirmed that nightly hemodialysis is available in hospitals, but is not available at home. Hemodialysis treatment is available at University of Benin Teaching Hospital, Onitsha General Hospital, Holy Rosary Specialist hospital and Iyi Enu Hospital in Onitsha and also the Central Hospital Sapele Rd, Oka, Benin City, University College Hospital, Ibadan, National Hospital – Abuja and Lagos University Teaching Hospital.
45. The CIN considered the availability of post-transplant blood testing facilities and the costs of these post transplant tests at 16.1.4 and 16.1.5. The relevant tests were not covered by the NHIS but public-private partnership schemes were available with estimated costs, depending on the type of test, at around 18,600 naira to 20,500 naira. At 16.1.6 and 16.1.7 the CIN set out renal medication and treatment costs (including nephrologist costs), and transplant costs (around 5 million naira which covered cost of surgery, post-and medication for up to 6 months), and 16.1.8 sets out details of post-transplant costs of care (which were roughly 400,000 naira per month).
46. I did not understand Mr Ume-Ezeoke to contend that treatment for dialysis was not available in Nigeria. Having regard to the above evidence I am satisfied that treatment, including haemodialysis, in respect of the appellant’s End Stage Kidney Disease is available in Nigeria.
47. The appellant did not provide any background evidence in respect of the availability and cost of HIV medication in Nigeria. There were no reports by clinicians and/or country experts with contemporary knowledge of or expertise in HIV treatment in respect of the availability of or alternatives to the combination of antiretroviral medication currently taken by the appellant.
48. Mr Ume-Ezeoke relied on 14.1.8 of the CIN which quoted from Avert, a UK-based internationally focused charity, that low levels of access to antiretroviral treatment remained an issue for people living with HIV, which meant that there were still many AIDS-related deaths in Nigeria, and the just 33% of all people living with HIV were receiving treatment in 2017. Poor treatment coverage and adherence meant that the number of AIDS-related deaths in the country remained high with 150,000 deaths in 2017. Weaknesses in the health system created a barrier to many people accessing or staying on treatment, and drug supplies were known to run out and cause stockouts, although the government was attempting to address this by strengthening supply change and improving logistics around treatment a priority. The report also noted that although accessing the antiretroviral drugs themselves was free, often patients were asked to pay for other services such as the running of tests.
49. The CIN does however confirm at 14.1.1 that Nigeria has a National AIDS and sexually transmitted infections (STIs) Control Programme (NASCP), and that the National Agency for the Control of AIDS (NACA) has been mandated to support the NASCP. According to the MedCOI country contact in the CFS 2017, the programme activity includes both free screening and treatment. The programme also covers treatment of the disease, including the treatment of opportunistic infection. At 14.1.2 confirmed that free HIV treatment may be available in all public facilities as well as in designated private facilities, and that there was no other eligibility criterion to have access to the services other than the clinical eligibility criteria and that free treatment was accessible to all people living with HIV/AIDS.
50. At 14.1.9 of the CIN reference was made to a Premium Times article from March 2021 which stated:
‘About 11.2 per cent of People Living With HIV (PLWHIV) in Nigeria still incur huge out-of-pocket costs for treatment, a new report has shown.
‘The report titled “Community-Led Monitoring (CLM) initiative on COVID-19 and HIV in Nigeria” showed that 212,800 PLWHIV in the country make significant out of pocket expenses to access treatment.
‘The report indicates that distance of treatment centres and out of pocket expenses are major barriers to HIV service accessibility.
‘“20.2 per cent of PLHIV do not have treatment centres close to where they live.”
‘Other barriers include side effects of HIV treatment, drug breaks, lack of confidentiality at site level, user fees for processing payments, stigmatization and discrimination amongst others.
‘Data for the report were collected between September and December 2020 by the Network of People Living with HIV/AIDS in Nigeria (NEPWHAN) with support from the National Agency for the Control of AIDS (NACA) and the UNAIDS.’
51. The background evidence nevertheless indicates that, whilst not equivalent to the UK, care is widely available and free. At 14.1.10 A MedCOI response from August 2020 noted that:
‘There are infectionologists, internists and HIV specialists in most tertiary centres and state HIV centres including: National Hospital, Abuja, University of Calabar Teaching Hospital, University of Portharcourt Teaching Hospital, Ahmadu Bello University, Zaria, University College hospital, Ibadan, Lagos State University Teaching Hospital, University of Ilorin Teaching Hospital, Ilorin, and Wuse District Hospital, Abuja.
‘The laboratory tests including CD 4 count are done in most of these establishments and viral load and resistance test for antiretroviral drugs in a few of them as well as some private laboratories e.g. Synlab in Lagos and Abuja.’
52. And at 14.1.13 the CIN stated:
A Boyd, AT, Jahun, I, Dirlikov, E et al in a September 2021 research publication ‘Expanding access to HIV services during the COVID-19 pandemic—Nigeria’, 2020 stated:
‘To accelerate progress toward the UNAIDS 90-90-90 targets [Targets are that by 2020 - 90% of people living with HIV will know their HIV status, 90% of all people with diagnosed HIV infection will receive sustained antiretroviral therapy and 90% of all people receiving antiretroviral therapy will have viral suppression181], US Centers for Disease Control and Prevention Nigeria country office (CDC Nigeria) initiated an Antiretroviral Treatment (ART) Surge in 2019 to identify and link 340,000 people living with HIV/AIDS (PLHIV) to ART…..
‘During February–September 2020, the reported number of PLHIV [persons living with HIV] initiating ART per month increased from 11,407 to 25,560, with the proportion found in the community increasing from 59 to 75%. The percentage of newly-identified PLHIV initiating ART with a 3-month ART starter pack increased from 60 to 98%. The percentage of on-time ART refill pick-ups increased from 89 to 100%. The percentage of PLHIV established in care receiving at least 3-month MMD increased from 77 to 93%. Among PLHIV initiating ART, 6-month retention increased from 74 to 92%.’
53. The CIN, at 14.1.14, set out a MedCOI report listing antiretroviral drtugs used in the treatment of HIV/AIDS which were available in Nigera. These included Co-trimoxazole and Emtricitabine, prescribed to the appellant.
54. Having considered the above evidence, and in the absence of any evidence specific to the appellant indicating that a combination of antiretroviral medications suitable for him would not be available in Nigeria, I find that HIV treatment is available in Nigeria.
55. Mr Ume-Ezeoke relied on 15.3.2 of the CIN which states:
The MedCOI response country contact in the CFS 2017 noted that ‘Nigeria does not have a specialized institution for the treatment of hepatitis, but there are specialized subunits in internal medicine departments of the tertiary healthcare centres … there is not a programme for a partial or total coverage of hepatitis treatment. Also, the country does not have a policy to improve access to healthcare and /or reduce the cost of treatment and/or medication… treatment is available geographically, as most tertiary healthcare centres across the country provide treatment for hepatitis. However, this contact specifies that it is mainly possible in urban areas and not economically accessible.’
56. This does however indicate that treatment for hepatitis is available in Nigeria, although it is mainly in Urban areas and is not economically accessible. I note the absence of any clear evidence that the appellant is currently receiving treatment for hepatitis B. The appellant has already completed treatment in respect of hepatitis C.
57. The appellant has not produced any evidence that any treatment he may require in respect of any continuing heart disease or liver disease, was not available in Nigeria. Mr Ume-Ezeoke did not identify or refer to any evidence that the appellant was continuing to receive treatment for liver or cardiac problems.
58. Having regard to this evidence in the round I find that medical treatment for all of the appellant’s medical conditions is available in Nigeria. He has not produced evidence capable of demonstrating that there are substantial grounds for believing that he would face a real risk of either a significant reduction in his life expectancy or of being exposed to a serious, rapid and irreversible decline in his state of health resulting in intense suffering, on account of an absence of appropriate treatment in Nigeria.
59. I must now consider whether the appellant has adduced evidence capable of demonstrating that substantial grounds have been shown for believing that he would face a real risk of either a significant reduction in his life expectancy or of being exposed to a serious, rapid and irreversible decline in his state of health resulting in intense suffering, on account of the lack of access to such treatment.
60. I have already set out at paragraphs 14 and 15 above, and again at paragraph 40 above, the background evidence that was before the First-tier Tribunal relating to the cost of dialysis treatment in Nigeria, and at paragraph 41 above I have set out the further evidence provided by the appellant for the remaking hearing relating to the same. I take into account the evidence in the CPIN dated November 2018, contained at paragraph 96 of the refusal letter indicating that chronic kidney disease treatment is not economically accessible and that most of the rural population is too poor to pay for the service and even if they could afford the treatment there was an absence of efficient transportation to enable access. This evidence must be considered in the context of the more up-to-date evidence detailed in the CIN report of December 2021.
61. I have additionally taken into account the evidence given by the appellant in his asylum interview, which is summarised at paragraph 17 above. I note in particular the appellant’s claim that he previously worked as a teacher earning 70,000 naira a month, that he came from a family of small holders in rural northern Nigeria, but his family made sacrifices for him to receive an education and that it was he who therefore provided financial support to the remainder of his family, and his evidence relating to the employment of one brother-in-law as a teacher and the other brother-in-law as a shop owner. I have fully considered the appellant’s claim that he ran out of money and this prevented him from completing his Masters degree in the UK and that friends and family in Nigeria were unable to pay the remainder of the money.
62. In his most recent statement he claimed that he hardly has anyone who is able and willing to support him if he was removed in his current condition. He referred to the deaths of his mother, his older brother and older sister, and stated that his fiancée had not been in contact with him since he failed ill. He claimed that his other surviving siblings were currently displaced due to the activities of bandits, insurgents and terrorists in their part of Nigeria. He claims that his family home has been destroyed by these outlaws and that there are no kidney dialysis centres in Nasarawa State.
63. In his oral evidence the appellant claimed that he would need to start looking for a job afresh if removed to Nigeria, and he claimed that his brother who died in 2020 had been his benefactor. The appellant explained that he paid his university fees in increments in the UK and that he had collected the money used to pay the university fees over a period of seven years by investing in agriculture, for example by buying feed for his animals, which he then sold to come to the UK. Although the appellant accepted that he would be able to look for work if removed to Nigeria he claimed he would be unable to pay for the dialysis during the time he was not working. The appellant said that he had eight remaining siblings, three brothers and four sisters, and then claimed that one of his sisters, who had lived in Abuja, died the previous week. There was no evidence in support of this particular assertion. He claimed that those who could financially help him had died and there was no one left to ask. He confirmed that he had lived in Abuja for over 10 years.
64. The appellant claimed that the husband of one of his sisters who lived in Abuja relocated to another part of Nigeria to contest an election, but failed. He didn’t return to Abuja. He claimed that the husband of his other sister who lived in Abuja was retired. He also claimed that he had not informed the sister of his circumstances, including his need for dialysis, because he believed she would ‘break down’. The appellant claimed that he used to be maintained in the UK by going to a food bank and he was supported by church members. The appellant indicated that he had a lot of friends in Nigeria. It was put to the appellant that, if his family home in Nasarawa State had been burnt down as he claimed by bandits then his family would have reported it to the police. The appellant claimed that there had been no report as “they don’t get justice.”
65. The initial burden rests on the appellant to adduce evidence capable of demonstrating that substantial grounds have been shown for believing that, as a seriously ill person, he would face a real risk of either a significant reduction in his life expectancy or of being exposed to a serious, rapid and irreversible decline in his state of health resulting in intense suffering, on account of an absence of appropriate treatment in Nigeria or the lack of access to such treatment.
66. For the following reasons I am not satisfied that the appellant has accurately disclosed his and his family’s socio-economic circumstances. There is a dearth of evidence relating to how the appellant funded his studies in Nigeria and in the UK and in respect of the support he claimed to have previously received from others, support that he claims has now stopped because of the death of those who previously supported him.
67. I am not satisfied that the appellant has adequately explained where the money came from for his education in Nigeria and the UK. Although raised as a point in the respondent’s skeleton argument, the appellant has offered no explanation as to how he was able to afford to undertake his economics degree in Nigeria. As stated in his entry clearance application the appellant has an economics degree from a university in Nigeria, and was able to demonstrate to the entry clearance officer that he had already paid university tuition fees of £5,760 (in respect of total fees of £11,395), and that he had access to adequate funds to cover maintenance fees of £9,000. No issue was raised by either the appellant or Mr Ume-Ezekeoke with the assertion at paragraphs 10 to 12 of the respondent’s skeleton argument that, in order for the appellant to gain the necessary 10 points under Annex C of the material Immigration Rules, he would have needed to show that he had funds available totalling £14,635. This is a significant amount. It suggests, in the absence of clear and independent to the contrary, that he hails from a financially secure background and that, as he had access to significant funds in the past, he would continue to have access to similar funds in the future.
68. In his asylum interview the appellant claimed that he had to sell property in order to fund his studies in the UK, but he has not provided any documentary evidence to support this assertion. Nor has any evidence been provided of his agricultural endeavours that he claimed in oral evidence allowed him to save enough money over the years to travel to the UK to study. There is nothing in the appellant’s entry clearance application to indicate that any property was sold in order to enable him to study in the UK, and no documents relating to the sale of property has been provided by the appellant.
69. In his asylum interview the appellant claimed that a friend, Samuel Peter, helped finance his studies until Samuel’s death in 2014, but the appellant has not produced any evidence of the financial support from Samuel Peter, or indeed of his death. In his oral evidence the appellant claimed that Samuel was a politician but again he failed to produce any evidence of this. The appellant additionally claimed in his asylum interview that he was able to pay the course arrears after receiving financial support from two of his previous students. There is however no independent evidence in support of this assertion.
70. Nor has the appellant produced any independent evidence in respect of how he was maintained and accommodated from the expiry of his visa on 30 January 2015 until he began receiving NASS support following his claim for asylum made on 30 April 2018. In his asylum interview the appellant claimed that he worked 20 hours per week in accordance with his tier 4 student Visa until his visa expired, and then he worked for Delaware North at the Emirates Stadium selling food and drinks. No evidence has been provided in relation to this claimed income. The appellant has not demonstrated how he was able to support himself in London on the basis of this work history alone. I note only by way of observation that the appellant was able to fund legal representation and to fund representation by counsel at the remaking hearing. I acknowledge the appellant’s evidence, detailed in his asylum interview and his oral evidence, that he receives NASS funding (described by him as Asylum Help), and that he receives food from his church (although in his asylum interview, at [49], he claimed to also get financial help from church members who would give him £5 or £10). There was however no evidence from anyone from the appellant’s church, and I do not in any event find that his receipt of this funding is inconsistent him having access to sufficient funds in Nigeria to enable him to access the medication he needs and his weekly dialysis sessions.
71. In his asylum interview the appellant claimed he was earning 70,000 naira in Nigeria as a schoolteacher. The appellant has not however produced any evidence to prove his salary, such as salary payslips, letters from his previous employer, or deposits into a bank account. Whilst I remind myself that there is no need for corroborate of evidence in this jurisdiction, I am entitled to take account of the absence of evidence that one would reasonably expect to be available. Given my concerns with the other aspects of the appellant’s evidence, I am not prepared to accept that his monthly salary in Nigeria was as low as 70,000 naira.
72. The appellant claimed in his asylum interview that it was he who provided financial support to his family in the past, but no independent evidence was produced in support of this assertion, and there was no evidence from any members of the appellant’s family in Nigeria confirming the same. The appellant has not produced any financial evidence relating to his family in Nigeria. There are no bank or savings accounts in respect of any of his family members, there are no documents showing their income and expenditure, and there are no statements from the appellant’s family members attesting to their financial circumstances in Nigeria save for the email from his brother. This is particularly surprising given the appellant’s claim to be on very good terms with his family members and to communicate with them often. When asked in cross-examination why there were no statements from his family members he stated that he did video calls with his family “so they can show me what I want to see.” The appellant’s answer was evasive and he did not adequately explain the absence of evidence from his family that would, on any reasonable view, have been relevant.
73. In his statement of 6 June 2022 the appellant claimed that he mother died in July 2020, that an elder sister died in November 2020, that that his older brother, [HNK], died in March 2020. Although there are no death certificates the appellant has produced photographs of what appear to be notices of the death of these family members and details relating to their burials. I am willing to accept that these family members have died. The appellant had not however produced any evidence in support of his assertion at the remaking hearing that it was his older brother, [HNK], who acted as his benefactor and who provided the appellant with financial support until his death. If [HNK] had been providing the appellant with financial support I would reasonably have expected to see some independent evidence of this such as money remittance slips. Such evidence should have been reasonably straightforward to obtain. The absence of such evidence undermines the appellant’s otherwise unsupported assertion that it was his now deceased brother who provided him with financial support. In his asylum interview the appellant claimed that most of his family continued to live in Nasarawa state, although there was no independent evidence in support of this assertion.
74. The appellant claimed he had two sisters living in Abuja, although he also claimed that one sister died last week. As already noted, there was no evidence to support this assertion. He now claims that one sister left the city because her husband (unsuccessfully) sought to obtain a political appointment elsewhere. The appellant has not however produced any independent evidence supportive of this assertion. Nor has he produced any evidence as to why this sister, even if she was no longer living in Abuja, would be unable or unwilling to provide some financial support to the appellant to enable him access the medication and dialysis he requires.
75. I do not find the appellant’s reasoning as to why he has not informed his other sister in Abuja of his medical condition and his financial needs to be credible. There is no independent medical evidence suggesting that this sister is particularly vulnerable or emotionally fragile such that she would not be able to cope if she knew of the appellant’s medical condition and his needs. On the contrary, as the appellant has stated that he is on good terms with his family in Nigeria, it would be surprising if she was not willing to assist him financially in respect of his medication, or indeed to accommodate him. I do not find the appellant’s explanation for his alleged failure to inform this sister of his medical condition to be credible given the significant consequences to him if he were unable to access the appropriate medical treatment and medication.
76. The appellant could provide no reasonable explanation the email said to have been sent by his brother on 10 November 2020 had not been placed before the First-tier Tribunal. I share the concerns expressed by the respondent with this email. It reads as if it had been written ‘to order’ to assist in the appellant’s appeal. Written at the beginning of the email, next to the appellant’s name, is “(little bro)”. The point was made by Mr Lindsay that the appellant would not need to be informed that he was [JK]’s little brother. Nor is it clear why in November 2020 the appellant’s brother would write and remind him that his older sister died in March and his mother in September 2020; presumably the appellant would have been made aware as soon as these deaths occurred given that he claimed he enjoyed a close relationship with his family in Nigeria. None of the assertions detailed in the email are supported by any extraneous or independent evidence, and there remains little verifiable and independent evidence of the socio-economic circumstances of the appellant’s family in Nigeria.
77. Nor is there any independent evidence that the alleged arson attack on the family home was ever reported to the Nigerian authorities. I would reasonably have expected such a serious attack to have been reported. The absence of such evidence, which one would reasonably expect to be available, undermines the appellant’s claim that his family home was attacked. I note photographs of what appears to be either a derelict or burnt out building (the quality of the photograph is poor), but without any independent information or evidence relating to this property, it could be a photograph of anyone’s property.
78. In his oral evidence the appellant indicated that he had lots of friends in Nigeria. He claimed that they would be unable to financially support him and they were struggling with finding employment, but the appellant has not provided any evidence from any of these friends relating to their own financial circumstances, and their ability and willingness to provide some financial support for the appellant.
79. The appellant is highly educated with an economics degree and he claims he has been employed as a teacher in Nigeria. Whilst I appreciate and accept that the appellant may face difficulties in obtaining full-time employment in Nigeria given the current need for three weekly dialysis sessions, he indicated in his asylum interview his willing to work as a volunteer in this country and the medical evidence provided does not suggest that he is incapable of undertaking employment. I find the appellant is someone who is capable of undertaking employment in Nigeria.
80. Given the Lack of detail and clarity in the appellant’s evidence regarding his and his family’s financial circumstances, I can attach only limited weight to his assertion that his other family members are subsistence farmers. Whilst I cannot entirely exclude the possibility that this assertion is true, given that the appellant is a university graduate, in conjunction with my other concerns with his evidence and with his ability to satisfy the entry clearance officer that he would have had available over £14,000 in order to study in the UK, I cannot accept his assertion that his other family members were mainly subsistence farmers.
81. I accept that the background evidence shows that the medical treatment needed by the appellant in Nigeria, particularly in relation to his End Stage Kidney Disease and his HIV diagnosis, is expensive, and that it is financially out of reach for a very large part of the Nigerian population. For the reasons I have given above I am not however persuaded that the appellant has adduced evidence capable of demonstrating that substantial grounds have been shown for believing that he would face a real risk of either a significant reduction in his life expectancy or of being exposed to a serious, rapid and irreversible decline in his state of health resulting in intense suffering, on account of the lack of access to such treatment. The totality of the evidence before me indicates that the appellant has close family in Abuja who would be able to assist him in terms of his accommodation and maintenance needs and in respect of the cost of the medical treatment that is demonstrably available in Abuja. He has failed to produce evidence in relation to his and his families socio-economic circumstances that one would reasonably expect to be provided. He has failed to produce independent evidence that would enable the Tribunal to assess his financial circumstances. In the absence of such evidence, and in light of his previous ability to undertake degree level studies in Nigeria and to demonstrate the availability of over £14,000 in respect of his, he has failed to provide evidence capable of demonstrating the existence of substantial grounds for believing that he would be unable to afford treatment.
Notice of Decision
The appellant’s Article 3 ECHR appeal is dismissed

Anonymity Direction
Pursuant to rule 14 of the Tribunal Procedure (Upper Tribunal) Rules 2008, the appellant is granted anonymity.
No-one shall publish or reveal any information, including the name or address of the appellant, likely to lead members of the public to identify the appellant. Failure to comply with this order could amount to a contempt of court.

Signed D.Blum Date: 10 June 2022
Upper Tribunal Judge Blum