UI-2024-005647
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The decision
IN THE UPPER TRIBUNAL
IMMIGRATION AND ASYLUM CHAMBER
Case No: UI-2024-005647
First-tier Tribunal No: HU/01627/2023
THE IMMIGRATION ACTS
Decision & Reasons Issued:
On 12th February 2026
Before
UPPER TRIBUNAL JUDGE NORTON-TAYLOR
DEPUTY UPPER TRIBUNAL JUDGE PARKES
Between
[F Z]
Appellant
and
SECRETARY OF STATE FOR THE HOME DEPARTMENT
Respondent
Decided without a hearing at Field House on 9 February 2026
ADDENDUM RE-MAKING DECISION AND REASONS
Introduction
1. This addendum re-making decision has been made further to the main re-make decision and accompanying directions, sent out on 30 January 2026. The appellant’s appeal was allowed out right on Article 8 grounds. In respect of Article 3 and the risk of suicide, the panel concluded that the appellant had met the relevant threshold test set out in AM (Zimbabwe). The respondent was directed to confirm whether or not she would continue to contest the appellant’s appeal in respect of this issue.
2. In compliance with the directions, on 4 February 2026 Mr Nappey, Senior Presenting Officer, confirmed that:
“… the SSHD accepts that the Article 3 suicide threshold has been met. The SSHD does not wish to produce any further evidence on Article 3 medical. As such, the SSHD invites the tribunal to allow the appeal on Article 3 suicidality (medical) grounds.
3. The respondent confirmed that she was not seeking a further hearing in this case.
4. At the time of drafting the current addendum decision, there has been no response from the appellant. In all the circumstances, we do not need to wait any longer in order to finally dispose of this appeal because the respondent has conceded that the appellant succeeds on the only outstanding issue.
Conclusions
5. In light of previous conclusion that the Article 3 threshold had been satisfied and in light of the respondent’s express concession in her response to directions, the appellant’s appeal is allowed on the additional basis of Article 3 (suicidality).
6. We add only a further brief comment. We are grateful once again to Mr Nappey for the efficient and if it may be said sensible manner in which he has conducted the respondent’s case right up until this final stage.
Notice of Addendum Decision
The decision in this appeal is re-made and the appeal is additionally allowed on Article 3 (suicidality) grounds.
H Norton-Taylor
Judge of the Upper Tribunal
Immigration and Asylum Chamber
Dated: 9 February 2026
ANNEX: THE ERROR OF LAW DECISION
IN THE UPPER TRIBUNAL
IMMIGRATION AND ASYLUM CHAMBER
Case No: UI-2024-005647
First-tier Tribunal No
HU/01627/2023
THE IMMIGRATION ACTS
Decision & Reasons Issued:
30 January 2026
Before
UPPER TRIBUNAL JUDGE NORTON-TAYLOR
DEPUTY UPPER TRIBUNAL JUDGE PARKES
Between
[F Z]
Appellant
and
SECRETARY OF STATE FOR THE HOME DEPARTMENT
Respondent
Representation:
For the appellant: Mr D Bazini, Counsel, instructed by Duncan Lewis Solicitors
For the respondent: Mr J Nappey, Senior Presenting Officer
Heard at Field House on 16 December 2025
RE-MAKING DECISION AND REASONS
Introduction
1. This is the re-making of the decision in the appellant’s appeal against the respondent’s refusal (dated 19 January 2021) of her human rights claim (dated 24 March 2020).
2. The appellant is a national of Ghana, born in 1975. She came to the United Kingdom on 28 May 2011 in possession of entry clearance as a visitor. She overstayed and has remained in this country unlawfully ever since. On Christmas Day 2013 she was the victim of a ‘hit and run’ road traffic accident. This resulted in significant physical, cognitive, and mental health problems which persist to this day.
3. An asylum claim was made in March 2018. This was refused by the respondent in October of that year and an appeal dismissed by First-tier Tribunal Judge Krish on 6 June 2019 (PA/12918/2018 - “the 2019 FTT decision”). There was no successful onward appeal.
4. Further submissions were put forward in March 2020. These were based on the assertion that returning the appellant to Ghana would violate her rights under Articles 3 and/or 8 ECHR. That assertion relied on the consequences of the 2013 accident, the care being received in the United Kingdom, and the absence of appropriate care and/or its affordability in Ghana. The further submissions were treated by the respondent as a fresh human rights claim and that claim was refused with a right of appeal. In that appeal the appellant relied not only on Article 8, but also Article 3 in respect of risk of suicide and the absence of adequate medical treatment in Ghana more generally. The appeal was dismissed by First-tier Tribunal Judge Bartlett on 18 October 2024 (“the 2024 FTT decision”). That decision was successfully challenged in the Upper Tribunal (“the UT”). By a decision sent out on 22 May 2025, Upper Tribunal Judge L Smith and Deputy Upper Tribunal Judge Durance concluded that the 2024 FTT decision contained material errors of law. They found that: (a) the judge had failed to have regard to evidence concerning the ability of the appellant’s three sons to provide her with financial support on return; (b) the judge failed to properly consider whether monitoring was an essential aspect of the appellant’s medical care; and (c) the judge failed to adequately address the appellant’s accepted subjective fears of returning to Ghana, as described in expert medical evidence.
5. In consequence of the errors found, the UT set aside the 2024 FTT decision as a whole and without preserving any findings. The case was retained in the UT, it being said that “[a]lthough the appeal involves complex issues of fact and law, those are quite narrow in scope, and it is therefore appropriate for the appeal to remain in the Upper Tribunal.”
6. Following the error of law decision being sent out, a case management review hearing was conducted on 24 October 2025 and directions were issued.
The issues in outline
7. The live issues before us are as follows:
Issue 1: Can the appellant meet the relevant legal threshold test in respect of a completed act of suicide if returned to Ghana?
Issue 2: If not, can the appellant nonetheless meet the relevant legal threshold test in respect of the availability and accessibility of appropriate medical treatment in Ghana?
Issue 3: If not, can the appellant succeed on private life grounds with reference to paragraph 276ADE(1)(vi) of the Immigration Rules (“the Rules”)?
Issue 4: If not, can the appellant succeed on Article 8 grounds outside the Rules?
8. There is no protection claim in play.
The legal framework in outline
Issues 1 and 2: Suicide and non-suicide medical claim under Article 3
9. We were not referred by the parties to the reported decision of MY (Suicide risk after Paposhvili) [2021] UKUT 00232 (IAC), but we have taken it into account. It concluded that when considering whether an individual could meet the Article 3 threshold, the overall framework set out by the Supreme Court in AM (Zimbabwe) v SSHD [2020] UKSC 17 applies to a ‘suicide claim’, as it does to non-suicide medical claims.
10. The Supreme Court’s conclusions can be found at [29]-[31] of its judgment. These, together with what was said subsequently by the ECtHR in Savran v Denmark (application no. 57467/15), are helpfully summarised at [17] of AM (Art 3; health cases) Zimbabwe [2022] UKUT 00131 (IAC) (“AM (Zimbabwe)”) and we adopt them:
“(1) Article 3 ECHR is an absolute and fundamental right. It prohibits in absolute terms torture and inhuman or degrading treatment or punishment and its guarantees apply irrespective of the reprehensible nature of the conduct of the person in question. In a removals case, where there is a real risk that an individual will face treatment contrary to Article 3 in the receiving state, removal cannot take place. In such circumstances, the responsibility of the removing state is engaged by the removal itself.
(2) The threshold which must be reached in order for treatment to breach Article 3 is high. Article 3 requires a “minimum level of severity”. As explained by the Supreme Court in AM (Zimbabwe) at [31], what is required to be shown is either a “serious, rapid and irreversible decline” in the applicant’s health “resulting in intense suffering” or “a significant reduction in life expectancy”. In this context, “significant” means “substantial” in line with the alternative of the serious implications on health leading to the intense suffering.
(3) As set out at [32] of AM (Zimbabwe) and reiterated at [130] of Savran, the burden is on an applicant to adduce evidence demonstrating “substantial grounds” for believing that it is a “very exceptional case” because of a “real risk” of subjection to treatment contrary to Article 3.
(4) Two important points emerge from this: first, it is for the applicant to adduce the requisite evidence - this is an application of the basic principle that “if you allege a breach of your rights, it is for you to demonstrate it”; second, the test represents a threshold which in the words of Lord Wilson in this case, is a “not undemanding” one. Whether the minimum level of severity is met is relative and depends on all the circumstances of the case.
(5) The first step is for the applicant to raise a “prima facie” case. As the Supreme Court said at [32] of AM (Zimbabwe), “[t]his means a case which, if not challenged or countered, would establish the infringement”. The Supreme Court referred with approval to the guidance provided by this Tribunal at [112] in AXB v Secretary of State for the Home Department [2019] UKUT 00397 (IAC).
(6) In the event that an applicant provides evidence which establishes a “prima facie” case or as the ECtHR refers to it, if the applicant meets “the threshold test”, it is then for the returning state to seek to counter that case ([32 and 33] of AM (Zimbabwe) and [135] of Savran). As the Supreme Court in AM Zimbabwe concluded, the reference in Paposhvili to a requirement to dispel “any” doubts must be read as meaning “any serious doubts”. That is further explained by the Grand Chamber in Savran as being an obligation not only to “dispel any doubts” raised by an applicant’s evidence but also “to subject the alleged risk to close scrutiny by considering the foreseeable consequences of removal for the individual concerned in the receiving State, in the light of the general situation there and the individual’s personal circumstances” ([130(b)]). The returning state must verify whether the care generally available in the receiving state is sufficient and appropriate, and the extent to which the applicant will actually have access to the treatment in question ([130(c) and (d)].
(7) Where, after the relevant information has been examined, serious doubts persist regarding the impact of removal on the applicant, the returning state must obtain individual and sufficient assurances from the receiving state as a precondition for removal, that appropriate treatment will be available and accessible – see [130(e)] of Savran and the sequence of the Paposhvili steps summarised within [23] of AM Zimbabwe.”
11. The judicial headnote of AM (Zimbabwe) is also a useful guide:
“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.”
12. We direct themselves to the well-known guidance set out in J v SSHD [2005] EWCA Civ 409, as reformulated in Y (Sri Lanka) v SSHD [2009] EWCA Civ 362. The six questions set out at [26]-[32] of the former are as follows:
“First the test requires an assessment to be made of the severity of the treatment which it is said that the applicant will suffer if removed. This must attain a minimum level of severity. The court has said on a number of occasions that the assessment of its severity depends on all the circumstances of the case. But the ill-treatment must ‘necessarily be serious such that it is ‘an affront to fundamental humanitarian principles to remove an individual to a country where he is at risk of serious ill-treatment’: see Ullah paras [38]-[39].
Secondly, a causal link must be shown to exist between the act or threatened act of removal or expulsion and the inhuman treatment relied on as violating the applicant’s Article 3 rights. Thus, in Soering at para [91], the court said:
‘Insofar as any liability under the Convention is or may be incurred, it is liability incurred by the extraditing contracting state by reason of its having taken action which has as a direct consequence the exposure of an individual to proscribed ill-treatment’ (emphasis added).
See also [108] of Vilvarajah where the court said that the examination of the Article 3 issue ‘must focus on the foreseeable consequences of the removal of the applicants to Sri Lanka …’
Thirdly, in the context of foreign cases, the Article 3 threshold is particularly high simply because it is a foreign case. And it is even higher where the alleged inhuman treatment is not the direct or indirect responsibility of the public authorities of the receiving state, but results from some naturally occurring illness, whether physical or mental. This is made clear in para [49] of D and para [40] of Bensaid.
Fourthly, an Article 3 claim can in principle succeed in a suicide case (para [37] of Bensaid).
Fifthly, in deciding whether there is a real risk of a breach of Article 3 in a suicide case, a question of importance is whether the applicant’s fear of ill-treatment in the receiving state upon which the risk of suicide is said to be based is objectively well-founded. If the fear is not well-founded, that will tend to weigh against there being a real risk that the removal will be in breach of Article 3.
Sixthly, a further question of considerable relevance is whether the removing and/or the receiving state has effective mechanisms to reduce the risk of suicide. If there are effective mechanisms, that too will weigh heavily against the applicant’s claim that removal will violate his or her Article 3 rights.”
13. The fifth question set out above was reformulated at [15] of Y (Sri Lanka) to include “whether any genuine fear which the appellant may establish, albeit without an objective foundation, is such as to create a risk of suicide if there is an enforced return.”
Issue 3: Paragraph 276ADE(1)(vi) of the Rules
14. Prior to its coming into effect on 20 June 2022, this provided in so far as relevant:
“The requirements to be met by an applicant for leave to remain on the grounds of private life in the UK are that at the date of application, the applicant:
(i) does not fall for refusal under any of the grounds in Section S-LTR.1.1. to S-LTR.2.2. and S-LTR.3.1. to S-LTR.4.5. in Appendix FM
(ii) has made a valid application for leave to remain on the grounds of private life in the UK; and
…
(vi) subject to sub- paragraph (2), is aged 18 years or above, has lived continuously in the UK for less than 20 years… But there would be very significant obstacles to the applicant’s integration into the country to which he would have to go if required to leave the UK.”
15. S-LTR.4.5 of Appendix FM provided for the discretionary ground of refusal where an NHS debt was owed.
16. When considering the question of integration, we direct themselves to the well-known passage at [14] of SSHD v Kamara [2016] EWCA Civ 813 and what is said at [25]-[26] of NC v SSHD [2023] EWCA Civ 1379:
“25. It is not in doubt, based on these authorities, that (i) the decision-maker (or tribunal on appeal) must reach a broad evaluative judgment on the paragraph 276ADE(1)(vi) question (see Kamara at [14]), (ii) that judgment must focus on the obstacles to integration and their significance to the appellant (see Parveen at [9]) and (iii) the test is not subjective, in the sense of being limited to the appellant's own perception of the obstacles to reintegration, but extends to all aspects of the appellant's likely situation on return including objective evidence, and requires consideration of any reasonable step that could be taken to avoid or mitigate the obstacles (see Lal at [36]-[37]).
26. I would add this. The test posed by paragraph 276ADE(1)(vi) is a practical one. Regard must be had to the likely consequences of the obstacles to reintegration which are identified. In a case like this, where the only obstacle identified is the appellant's genuine but unfounded fear, particular care must be taken to assess the ways in which and the extent to which that subjective fear will or might impede re-integration. It cannot simply be assumed that it will. The likely reality for the appellant on resuming her life in her home country must be considered, given her subjective fear, and the availability of support and any other mitigation must be weighed. It is against that background that the judgment on whether the obstacles to reintegration will be very significant must be reached.”
Issue 4: Article 8 outside the Rules
17. We direct ourselves to the well-known step-by-step approach set out in Razgar and the importance of the Rules when considering proportionality, as made clear in Agyarko v SSHD [2018] UKSC 11, at [46]-[48].
18. We also remind ourselves of the mandatory considerations set out in section 117B of the Nationality, Immigration and Asylum Act 2002, as amended (“ NIAA 2002”), in particular those concerning the public interest, public funds, and unlawful status.
The evidence
19. We have carefully considered the relevant evidence contained in the appellant’s consolidated bundle, indexed and paginated 1-693. The most important aspects of that evidence, as reflected by the written and oral submissions put to us, are:
(a) The appellant’s witness statements, dated 4 March 2022 and 6 June 2024;
(b) The combined witness statement of the appellant’s two biological sons, Nana Yaw Asante and Nana Bafour Akoto, dated 26 May 2024;
(c) The witness statement of the appellant’s adopted son, Richard Yaw Tetteh, dated 28 June 2024;
(d) The various letters and reports of Dr Imran Chishti, Consultant Psychiatrist and the appellant’s treating clinician since at least 2023;
(e) The medico-legal report of Dr Syed Ali, Consultant Psychiatrist, dated 4 November 2025;
(f) The country report by Dr Akin Iwilade, Senior Lecturer in African Studies at the University of Edinburgh, dated 23 October 2025.
20. It is of note that the reports of Dr Chishti and Dr Ali have not been challenged by the respondent.
21. We have also been referred to the respondent’s CPIN, “Ghana: Medical treatment and healthcare”, version 2.0, published August 2022.
22. We have had recourse to the respondent’s bundle prepared for the 2024 First-tier Tribunal hearing, as it includes the 2019 FTT decision and the respondent’s decision now under appeal.
23. On the basis of the clear medical evidence, the appellant was not called to give evidence. Indeed, she had been advised by her legal representatives not to attend the hearing at all in order to avoid possible distress.
The hearing
24. The hearing proceeded by way of submissions only. We express our gratitude to Mr Bazini and Mr Nappey for their assistance in what is undoubtedly a difficult case. We intend no disrespect to either by omitting to set out their submissions in any detail. These are a matter of record and we have subsumed their content within our consideration of the evidence and the legal conclusions following therefrom.
25. In brief summary, Mr Bazini relied on his skeleton argument and took us through the 2019 FTT decision and relevant evidence. All aspects of the appellant’s case were relied on. It is right to say that a fair amount of his submissions were focused on the questions of the ability of family members to financially support the appellant’s subjective fear is held by the appellant, and the availability and/or accessibility of monitoring treatment in Ghana.
26. Mr Nappey relied on the review document prepared by another Senior Presenting Officer who had not had sight of the latest evidence, namely the reports from Dr Ali and Dr Iwilade. He also relied on the reasons for refusal letter and made concise oral submissions. He specifically argued that the appellant could obtain appropriate support from family members in Ghana as regards medical treatment and general care.
Matters now accepted by the respondent
27. During the course of submissions, Mr Nappey confirmed that certain matters were now accepted. It was apparent to us that these concessions were properly made and followed what was obviously a careful consideration of the evidence and submissions put forward by the appellant.
28. It is to his credit that Mr Nappey was able to assist in narrowing down the disputed issues. The respondent now accepts the following:
(a) The NHS debt previously accrued by the appellant was cancelled by the NHS on 25 September 2024 and there is no longer any outstanding sum;
(b) The appellant is a “seriously ill person” and thus it is accepted that the appellant has answered the first question in the guidance set out by the UT in AM (Zimbabwe);
(c) Monitoring of the appellant’s mental health is an essential component of her overall treatment;
(d) In order to access appropriate treatment in Ghana, the appellant would have to rely on financial assistance from family members;
(e) If the appellant could not obtain appropriate treatment in Ghana, there is a real risk of her being exposed to “a serious, rapid and irreversible decline in his or her state of health resulting in intense suffering” and thus (ii)(a) of the second question under the AM (Zimbabwe) guidance would be answered in her favour.
Findings of primary facts
29. In making the relevant findings of fact we have, as we are bound to, considered the evidence as a whole. We place no adverse weight on the fact that the appellant has not herself given evidence.
30. We again observe that the expert medical evidence has not been challenged by the respondent.
31. We also observe that is the case in which the location of the burden of proof on the appellant is of particular importance. Having said that, we direct ourselves that the appellant is not required to provide “clear proof” of their claim that they would be exposed to treatment contrary to Article 3: Savran, at [146] and AM (Zimbabwe), at [27].
The appellant’s diagnoses, current medical treatment, prognosis, and care plan
32. On the basis of the unchallenged evidence from Dr Chishti and Dr Ali, we find that the appellant suffers from cognitive impairment/deficits (memory loss and other functional problems), paranoid schizophrenia/organic psychosis, PTSD, and severe depression. In addition, she has a number of physical difficulties relating to mobility and her ability to self-care.
33. As of now, we are satisfied on the evidence as a whole that the appellant is being prescribed Olanzapine at 15mg and Venlafaxine at 150mg. In respect of the former, we note that in his letter of 14 November 2025, Dr Chishti instructed the appellant’s GP to increase the dosage from 10mg to 15mg. The increased dose is referred to in Dr Ali’s report, although that report pre-dates Dr Chishti’s letter.
34. The evidence indicates a fluctuation in the appellant’s psychosis and, in consequence, the dosage of Olanzapine. This supports Mr Nappey’s acceptance that monitoring comprises an essential component of the appellant’s overall treatment.
35. We find that the monitoring has been undertaken by Dr Chishti since June 2023, following referral by the GP. We were not referred to medical evidence predating Dr Chishti’s supervision, but having considered the earlier evidence we note that it appears as though the monitoring was overseen by a Locum Consultant Psychiatrist, Dr Abbass Mohammadinasab.
36. The medical evidence does not state that there are no appropriate alternatives to the appellant’s current medication regime.
37. Dr Chishti confirms that the appellant’s prognosis for the PSTD and psychotic disorder “is good as long as [she] continues to engage well with her treatment.” It is clear that to date, the appellant has engaged well with her treatment. She has never been under a depot regime for her anti-psychotic medication.
38. At paragraph 16.3 of his report, Dr Ali concludes that:
“It is most likely that there will be a steady downward spiralling of her conditions and will never attain pre-morbid functioning or stability. In short, her Prognosis is rather poor with her current level of care and treatment. She is just existing without an ongoing neuropsychiatric treatment plan.”
39. To the extent that there is a difference between the experts’ conclusion on this particular point, we prefer that of Dr Chishti, he being the appellant’s treating clinician and having a wider and deeper knowledge of her overall medical circumstances.
40. We find that the appellant has been under a care plan from the local authority. Currently, this extends to 3 hours of at-home assistance a week, with 1 hour dedicated to support with accessing shops and a food bank, 1 hour for support with batch cooking, and 1 hour for support with laundry and domestic tasks. In our view, this does not represent a particularly significant level of care input.
41. Dr Ali is of the opinion that the current care package is inadequate and that the appellant requires 24 hour low-level support. However, the current care plan has been based on a detailed assessment by the local authority’s Adult Social Care team. Dr Chishti has not raised a concern with the current plan. As a whole, we find that the evidence before us does not indicate that the appellant currently requires a significantly greater level of care provision in order to remain safe and to remain compliant with her treatment regime. Having said that, for reasons set out later in our decision it is clear to us that her circumstances on return to Ghana would be much more challenging.
The appellant’s subjective fears of return
42. We accept that the appellant has genuine subjective fears about returning to Ghana. Those fears have been consistently expressed in her own evidence and the 2019 FTT decision expressly found that the appellant held genuine fears about being robbed, sexually abused, and/or being placed in a “which camp”, although the judge ultimately concluded that those fears were not well-founded because of protective factors (in particular, the presence of numerous family members in Ghana). We have not been asked to go behind the finding in the 2019 FTT decision. In any event, the general consistency of the appellant’s evidence, combined with her mental health conditions, would lead us to the same finding.
Medication available in Ghana
43. We are satisfied that Olanzapine is currently available in Ghana. The CPIN includes evidence to indicate that it is available from a private facility in Accra (the appellant’s home area and where her sons live): 20.3.1. None of the expert evidence or country information suggests that this medication is not in fact available, or that its supply is inconsistent/intermittent.
44. Venlafaxine is not listed in the CPIN evidence. However, we have previously noted that none of the medical evidence states that an alternative antidepressant medication would be inappropriate. We find that at least two antidepressant medications, sertraline and mirtazapine, are available in Accra. Subject to what we say about appropriate monitoring and in the absence of medical evidence to the contrary, we find that the appellant would be able to take alternative antidepressant medication which is available.
The availability of monitoring in Ghana
45. This issue has been difficult to determine. We would certainly have been assisted by more precise expert evidence on the Ghanaian mental health care system and that is relevant, given the location of the burden of proof. The ability of an individual to meet the demanding threshold test in Article 3 medical cases will often come down to the granularity of the evidence: AM (Zimbabwe), at [26].
46. We do not know whether the appellant’s representatives attempted to obtain expert evidence from, for example, a healthcare professional or academic based in Ghana with specific knowledge of mental health treatment and its availability. With respect to Dr Iwilade, his expertise does not lie in the mechanics of the Ghanaian mental health care system and much of his report is of a general nature, based on readily available country information (contained, for example, in the CPIN) and/or addresses irrelevant matters (for example, data protection, internal relocation within Ghana, and protection-related matters).
47. We accept that the Ghanaian health system is underfunded and faces significant challenges. That is true in respect of mental healthcare provision, as in all other areas. Country evidence, referred to by Dr Iwilade in his report, states that only 2.8% of mentally ill people are able to access treatment. That is clearly a very low figure, although we have not been provided with evidence as to whether it relates to every person with mental health conditions, or only those who cannot pay for treatment. Further, we have no evidence on whether the fact that the appellant would return to Ghana with a treatment regime in hand (i.e. a pre-existing history of medical care including the types of appropriate medication and monitoring) would be of benefit when seeking to re-establish treatment in that country. In other words, the appellant would not be starting ‘from scratch’ when it came to medical intervention for her conditions. We appreciate that some these points may appear speculative, but in our view they are relevant and are, particularly given the burden of proof, relevant to reasonable inferences which we are able to draw from the evidence which is before us.
48. We note from Dr Chishti’s letter of 14 November 2025 that he suggested an “OPA” (out patient appointment) in two months’ time. Although we have not been provided with a clear history of such appointments, we take that as an indication of the frequency of monitoring that has been undertaken in recent times.
49. We have already found that the appellant’s monitoring in the United Kingdom has, at least for a number of years, been overseen by a Consultant Psychiatrist. We have some doubts as to whether a psychiatric nurse would be unable to carry out the appropriate monitoring, particularly if provided with the appellant’s medical records from the United Kingdom, but are prepared to accept that a psychiatrist would be the appropriate professional.
50. In terms of the situation in Ghana, Dr Iwilade states that the ratio of psychiatrists to population is 0.058 per 100,000. At 20.1.1 of the CPIN, it is said that there were 39 psychiatrists as of 2020 (Dr Iwilade also refers to this). The source material for the CPIN figure (the World Health Organisation Mental Health Atlas 2020) states the ratio to be 0.13 per 100,000. We prefer the latter to the former, given that no sources are provided for the lower ratio figure. In any event, we accept that the level is low. Having said that, the evidence indicates that the majority of psychiatrists are located in Accra, which is where the appellant would be residing (that being the place of residence of her children).
51. Taking the evidence that we have in the round and reminding ourselves that the appellant need not establish clear proof that monitoring is not available, we nonetheless conclude that the appellant has not adduced evidence capable of demonstrating substantial grounds for believing that the type of monitoring required by the appellant would be unavailable in Ghana, albeit that such monitoring would likely come at a cost.
The cost of treatment
52. We have no evidence from the appellant on the cost of the specific required treatment, namely the medication and monitoring. We cannot tell, for example, whether one or both of the necessary elements would on any view be prohibitively expensive relative to average earnings in Ghana. We see from 20.2.1 of the CPIN that the cost of “outpatient and ongoing psychiatric treatment” at a public hospital in Accra in 2020 was 80 Ghanaian Cedis, but we cannot assess whether that is particularly expensive and what the sum would cover.
53. We note from 2.3.2 of the CPIN that chronic mental health patients are exempt from having to pay the annual premium for the national health insurance scheme. We cannot tell for sure whether the scheme would cover part of the cost of the appellant’s treatment, but nothing in the evidence before indicates that it would not. We have not been presented with evidence to indicate that those with pre-existing medical conditions would be barred from the scheme.
54. We acknowledge that the appellant’s adopted son states that the national health insurance scheme “does not cover the complex medical care she needs”, but with respect, we do not regard that as constituting reliable evidence. He is not an expert and he provides no detail as to why that might be the case.
55. The CPIN confirms that private health insurance is available in Ghana. We have not been provided with any reliable evidence to indicate that such insurance would be prohibitively expensive, or that the appellant would for some other reason be precluded from taking such insurance out (for example, having pre-existing medical conditions). We have not been provided with evidence that, for example, limited private health insurance could not be combined with the national health insurance scheme to assist the appellant with the costs of treatment. Even if private health insurance was not an option, we nonetheless conclude that the appellant has failed to meet the evidential threshold in respect of other potential sources of financial support, having regard to the national health insurance scheme, the country evidence, and family assistance.
56. The appellant has relied on 20.1.1 of the CPIN and the source material for the figures set out therein (relating to the number of psychiatrists and mental health facilities in Ghana) states that the majority of persons with mental health conditions pay “at least 20% towards the cost of services and medicines” (footnote 152: Mental Health Atlas 2020). That strongly suggests that persons in the appellant’s position would not have to pay the full cost of treatment.
57. Having regard to the evidence as a whole, the appellant has failed to adduce evidence capable of demonstrating substantial grounds for believing there to be a real risk that the cost of appropriate treatment in Ghana would inevitably be prohibitively expensive.
Family and/or other support in Ghana
58. In light of the respondent’s concessions and our findings on the availability and accessibility of appropriate medical treatment, the question of family support in Ghana is a core aspect of the appellant’s case.
59. Before turning to the question of financial support, we have no doubt that the appellant’s three sons would be willing to provide emotional and non-financial practical support if she were returned to Ghana. The contrary has not been suggested.
60. We do not find that she has been deliberately untruthful in her written evidence as regards contact with her sons. It is possible, indeed likely, that her significant memory problems may have caused her to forget things that have in fact occurred. We find it difficult to accept that she has not had any contact with at least her three sons in recent times. They provided evidence in support of her 2024 FTT and they are clearly aware of her circumstances in this country. It is likely that she was aware of their evidence having been provided. They live at a stable address and it will have been easy to make and maintain contact. There is no evidence before us that the appellant is estranged from her sons in the sense of any hostility or rejection. Further, we note from a Memory Service assessment from March 2021 that the appellant confirmed that she kept in contact with her sons by telephone.
61. In the first instance, we do not accept that the appellant has “lost contact with the only family I had in Ghana”. We find that she has had contact, even if this has been irregular.
62. Even if she has not had recent contact, we find that it is entirely feasible for her to re-establish contact (perhaps with support) with at least her sons prior to and in preparation for a return to Ghana.
63. Following from the above, we find that notwithstanding the passage of time and the dramatic change in her circumstances, the appellant’s sons would not reject her if she were to return.
64. We turn to the question of financial support. The evidence as a whole satisfies us accept that the appellant would not be in a position to generate her own income on a consistent basis.
65. In light of the Devaseelan guidelines, we take as our starting point the findings of the 2019 FTT decision. At that point in time (April 2019), the respondent accepted that the family members in Ghana (siblings and the three sons) were unable to provide financial support: [45]. At [97], the judge found that to be the case, although importantly she observed that “the situation may change.”
66. We do not regard this starting point as being particularly strong. The relevant findings were made 6 ½ years ago. The judge’s observation that the situation may change over time was in our view clearly appropriate. The appellant was on notice even then as to the importance of adducing good evidence about the financial means of the family members in any future representations/appeals.
67. The respondent’s 2021 reasons for refusal letter clearly stated her view that family members would be able to financially support the appellant on return to Ghana and that position has not altered.
68. We turn to the 2024 FTT decision and the UT’s error of law decision. The judge did not accept that the family members (the three sons and/or the siblings) would be unable to financially support the appellant in terms of appropriate medical treatment: [13]. In its error of law decision the UT accepted that the judge had been entitled to reassess the evidence on financial support given the passage of time since the 2019 FTT decision, but concluded that there was an error in the failure to have adequately addressed the adopted son’s evidence: [22]-[23].
69. We of course acknowledge that none of the findings in the 2024 FTT have been preserved and we do not treat any of them as such.
70. However, two matters arising from the 2024 FTT decision and the UT’s decision are of significance here. First, the appellant was again clearly put on notice that the question of familial financial support was very much a live issue. Secondly, the UT did not conclude that the judge had erred in her finding that other family members could financially support the appellant and so the error identified at [22]-[23] might not have been material: [23]. Indeed, the judge’s finding on the other family members was not challenged in the grounds of appeal.
71. Thus, the appellant was not only on clear notice as the importance of adducing evidence on the circumstances of the three sons, but also in respect of the other family members in Ghana.
72. In the event, the only evidence we have is that of the appellant and the statements of the two biological sons (May 2024) and her adopted son (June 2024). In light of what we have already said and the applicable legal framework, the absence of any updated evidence from the sons and the absence of any evidence whatsoever from the other family members in the intervening 18 months is significant.
73. We accept that the sons have not provided financial assistance to the appellant whilst she has been in the United Kingdom. That is perhaps unsurprising, as her care and treatment has been provided free of charge in this country.
74. We find that the appellant’s younger biological son is now 17 years old. Given his age, it is plausible that he remains in education at IPMC in Accra (that institution appears to be an IT technology college). Notwithstanding the absence of updated evidence, we are prepared to accept that he is not working and is financially dependent on others.
75. Our conclusions on the position of the appellant’s older biological son is different. The 2024 FTT decision and the UT expressed concern as to why, at the age of 24, he was still in education. We share that concern in relation to the position in May 2024. That concern is heightened by the absence of updated evidence as of December 2025, when he was 26 ½ years old. We have not been provided with any evidence as to what “level 200” meant in respect of his education as at May 2024. Even if it related to a course equivalent to a Masters, we find it to be highly unlikely that he remains in education 18 months later. Rather, we infer from the evidence before us that he will have obtained relevant IT qualifications and completed his education.
76. Whilst we acknowledge that the absence of evidence does not necessarily imply evidence of absence (or in this case, a positive alternative scenario), the lack of any updated information on the eldest biological son’s circumstances leads us to find that he has in fact found employment.
77. An additional consideration, although not decisive for the primary finding just stated, is the fact that the older biological son (and indeed the adopted son) would understandably much prefer the appellant to continue receiving free high quality treatment in the United Kingdom rather than becoming a financial ‘burden’ on them: in other words, it is in their interest to maintain the status quo.
78. If, as we have found, the older biological son is in employment, we find that he is not currently the financial responsibility of the adopted son. Consequently, we find that he is in a position to financially contribute to the appellant’s medical treatment.
79. If we were wrong in finding that the older biological son is in employment and if he is in fact still in education, we find that there is no evidence to suggest that he could not, or would be unwilling to, cease his studies in order to assist his mother. That would clearly be a sacrifice, but there is no evidence from him or anyone else to indicate that those studies, as at December 2025, are of critical importance to his employment prospects.
80. We turn to the appellant’s adopted son. We accept that he was the only earner in the household as at June 2024. The documentary evidence provided in support of his income was and remains sparse (a single payslip), but we are prepared to accept that it was as claimed. The absence of updated evidence from him means that we do not know his current salary. Experience of these matters in general would suggest that it increased over time. It may also be that the cost of living in Ghana has increased with inflation, although we have no evidence about this.
81. In light of our findings on the eldest biological son, we find that the adopted son does not or need not now bear the costs (at least the entirety of those costs) of maintaining him. Having regard to this and all that we have said about the appellant’s treatment, we find that the adopted son would, if necessary, be able to fund the treatment, whether alone or in combination with funds from the older biological son.
82. We therefore reject Mr Bazini’s submission that there is nothing to displace the evidence provided in May/June 2024 and that it is “fanciful” to suggest that the sons could fund the appellant’s medical treatment.
83. We acknowledge that financial support for the appellant would involve significant sacrifices for the three sons. It would also place a not inconsiderable practical burden on them in terms of providing care for their mother. We find, though, that such care would be given, at least to a tolerable level. This finding is in truth limited to our overall consideration of the demanding threshold test under Article 3. It says relatively little about the appellant’s ability to reintegrate into Ghanaian society if she were returned. That is a question we shall return to in due course.
84. We turn to the appellant’s siblings. We are prepared to accept that she has not had contact with them for some time. We accept that they have not thus far financially supported the appellant in this country. As with her sons, this is unsurprising.
85. The appellant has not adduced evidence of attempts to make contact with her siblings, whether directly or through her sons in Ghana. We do not speculate as to whether any attempts had been fact been made. However, given what is said in the 2024 FTT decision, the potential ability of those relatives to financially contribute is a material consideration which is left unaddressed by the appellant and her sons. If it is contended that re-establishment of contact is simply not possible, we reject this. In her 2025 statement, the appellant claims that she lost contact with her siblings because of her absence from Ghana and that she was considered “a burden on them”. Yet that does not answer the question of whether she (or her sons on her behalf) could make contact and whether one or more of her numerous siblings would be willing and able to provide some form of financial contribution to her treatment on return, even if it were in relatively small sums. On what we have, we find that the appellant has failed to show that no such assistance would be forthcoming.
86. In her latest statement, the appellant claims that she has friends in the United Kingdom who support her emotionally and financially, and are “willing to continue to do so.” We have no evidence from these individuals and this issue was not canvassed before us, but we are entitled to consider what the appellant had said. If some form of financial support has been provided in this country, there is no good reason why, at least to an extent, this could not continue if she were returned to Ghana. We find that it could.
87. There is a letter from the appellant’s church, dated 29 May 2024, confirming that she had been provided with some financial support, including “occasional donations”. Again, there is no evidence to suggest that this would simply cease if she were returned to Ghana and, in the context of the source of that financial support, we find it to be highly likely that some form of provision would be continued if that scenario arose.
88. Bringing all of the above together and once again reminding ourselves of the burden of proof and that the appellant need not provide clear proof on the relevant issues, we find that there would be financial and other practical support for the appellant such as to make the available medical treatment accessible to her on an appropriately consistent basis and beyond the period immediately following return.
Issue 1: Conclusions on the risk of a completed act of suicide
89. In the context of the present case, it is the fifth and sixth questions set out in J v SSHD (as reformulated in Y v SSHD) which are of relevance.
90. We have not overlooked the fact that the 2019 FTT decision concluded that there was no real risk of completed suicide occurring: [98]. Whilst of some relevance, the passage of time and the body of evidence before us significantly reduces the import of that conclusion.
91. The appellant’s fears of returning to Ghana are, as we have already found, genuinely held but not objectively well-founded, for reasons set out by set out in the 2019 FTT decision and the 2024 FTT decision.
92. We remind ourselves that those subjective fears are of what would be, if they were to materialise, serious harm to her (being taken to a witch camp and/or sexually abused). In the context of the appellant’s significant cognitive and mental health conditions (including poor memory, command hallucinations, PTSD, and severe depression), it is highly likely that the subjective fears of serious harm are entrenched and are highly unlikely to simply dissipate or even significantly lessen on or after arrival in Ghana, even if other protective factors were present. Being with her sons would no doubt be of some comfort, but she would at the same time have to contend with the challenges of re-establishing relationships with them and actually being in the country in which her subjective fears are believed to exist.
93. It is to be observed that this is not a case in which the appellant has in fact previously been ill-treated in Ghana. Her situation contrasts with the facts in Y v SSHD, where the individual had been tortured and sexually abused by the Sri Lankan authorities. Thus, the appellant’s subjective fear is not based on actual past experiences in the country to which she would be returned. That distinction does not however carry particularly significant weight in our assessment. Her entrenched subjective fears persist despite the absence of past ill-treatment, a state of affairs which is consistent with her very significant mental health and cognitive problems.
94. We turn to what the expert medical evidence has to say about the risk of suicide. In doing so, we are satisfied that on a fair reading of the reports from Dr Ali and Dr Chishti, they have based their opinions on the appellant’s clear statements that she would kill herself if returned to Ghana and that these were to be taken seriously, when considered in the context of her significant mental health conditions. Those opinions cannot properly be taken as nothing more than a simple reliance on the appellant’s statements: it is clear to us that they were formed following an overall professional assessment. In fairness to the respondent, she has not put forward any arguments against such a conclusion.
95. We cannot be certain that the stated intent to take her own life was predicated on the appellant’s subjective fears previously referred to. In light of the evidence, we draw the inference that the appellant’s stated intent is probably based on a combination of the subjective fears and a contemplation of what her situation would be on return to Ghana. Whatever the true position is, the unchallenged opinions of the medical experts require careful consideration.
96. Dr Ali’s opinion is that the appellant “is at significant risk of suicide in view of her ongoing mental health conditions”: [26]. It is recorded that the appellant “categorically” stated that she would end her life if forced to return to Ghana. Later in his report, Dr Ali states that the appellant would be “at the highest risk committing suicide”. That particular view would appear to be predicated on the scenario that the appellant would not have access to appropriate treatment: [31.1]. However, at [32.1], he goes on to repeat the appellant’s categorical statement of intent to take her own life if returned to Ghana and then opines that, “Therefore, at any point such a decision is made, she will be at a very high risk of committing suicide.” On our reading of the report, the “very high risk” is not therefore linked simply to the provision or otherwise of appropriate treatment, although an absence of this would, in Dr Ali’s view, create “the highest risk” of a completed act of suicide. We also take into account that the particular wording used by Dr Ali at [32.1] perhaps suggests that the “high risk” would rise only at the point that a removal decision was made (i.e. whilst the appellant was still in the United Kingdom). In our judgment, that would be an artificially narrow interpretation of his overall opinion. The receipt of a removal decision is highly likely to represent a significant risk factor. Having said that, given the evidence as a whole, we find it to be extremely unlikely that the appellant’s threat to take her own life “if she was returned to Ghana” is confined only to a point in time when she received a removal decision in this country. Again with reference to the evidence as a whole, it is highly likely that the process of removal itself and then the period of time immediately following return and into the short-term thereafter (months) would fall within the “high risk” category
97. In his 2023 report, Dr Chishti was of the view that there was a “low” risk of self-harm/suicide. The appellant had reported “occasional suicidal thoughts” but had no active intent plan. In his May 2024 report, Dr Chishti reported that the appellant had experienced command hallucinations to harm or even kill herself and that she would commit suicide if returned to Ghana, although she had no specific plans at that point. He then says the following in respect of suicide risk:
“Since I have known her - June 2023 - she has complained of intermittent suicidal thoughts, with no plan or intent. She reports that a strong Christian religion and children are protective factors that stop her from acting on these thoughts. [The appellant] also report voices that command her to harm herself, for example, by jumping into oncoming traffic. She has not acted on these commands.
…
There is no history that I am aware of her harming herself or any suicide attempts. She also mentions command hallucinations that tell her to harm or hurt herself, but she is able to manage to resist these with the help of her prescribed medication. However she has mentioned to me that should she have to return to Ghana, she would “rather die” and kill herself. This is therefore a high risk to herself in the circumstances, and it would be necessary to monitor this.
…
She has also stated that she might as well die and will kill herself if she has to return to Ghana. Although she has not specified a plan to do this the risk to self I would consider to be high.”
[Underlining added]
98. In his letter of 14 November 2025, Dr Chishti reports that the appellant denied having suicidal thoughts and had “occasional thoughts of harm to herself due to voices”, although she would tell them to “go away”.
99. As we have previously stated, where there are material differences between the opinions of Dr Ali and Dr Chishti, we have preferred those of the latter, given his position as the treating clinician. In respect of the suicide issue, Dr Ali has said that the risk is “very high”, whilst Dr Chishti has put it at “high”. Taking the lower classification, it nonetheless clearly represents a significant and unchallenged opinion.
100. At this stage, it is important to address what we consider to be a valid and significant distinction, as highlighted by Mr Bazini. At a number of points in his reports and letters over the last two or three years, Dr Chishti has recorded a view that risk of suicide has been “low”, that the appellant had no firm suicidal plans, and that she had been able to resist command hallucinations: see for example his May 2024 report. Mr Bazini submitted that these particular views were predicated on the appellant’s situation whilst in the United Kingdom and that both Dr Chishti and Dr Ali’s opinions on the risk of suicide on return to Ghana do not sit in tension with what they have said about the present risk. With particular regard to Dr Chishti’s evidence, we agree. It is clear enough to us that Dr Chishti’s evidence as a whole provides his opinions both as to present risk and future risk if removal to Ghana were to occur. Indeed, it would be somewhat surprising if, as the treating Consultant Psychiatrist, he had not undertaken that two-stage approach.
101. Therefore, we find that we are able to place very significant weight on, in particular, the unchallenged expert opinion of Dr Chishti as to the risk of suicide on return to Ghana. It is, at least, “high”. In this regard, Dr Chishti’s evidence is of primary importance. We do not, however, discount Dr Ali’s opinions. It is quite clear from his unchallenged report that he regards there is being a significant risk of suicide. Taking his evidence in the round, we still attribute significant weight to it, albeit that we prefer the “high risk” attribution by Dr Chishti to the even higher level stated by Dr Ali.
102. We turn to the existence of protective factors. The appellant herself has identified her Christian faith and her three children as representing such factors. These have also been recorded by Dr Chishti. We too consider these as, in principle, representing protective factors mitigating against the risk of suicide. However, there are certain countervailing considerations. First, we are satisfied that Dr Chishti had these protective factors in mind when he stated his opinion that there was nonetheless a “high risk” of suicide if the appellant was returned to Ghana. Before stating that opinion, he had referred to those factors and we are not prepared to find that he had simply forgotten about them when subsequently setting out his conclusions on risk. Secondly, the point just made is supported by what is said at [44] of the UT decision: the panel was clearly of the view that Dr Chishti had reached his “high risk” classification notwithstanding the protective factors. Thirdly, we place the protective factors in context. Notwithstanding their existence whilst the appellant is in the United Kingdom, she is still experiencing significant psychotic episodes, including command hallucinations. She holds entrenched subjective fears of returning to Ghana. She has categorically stated that she would take her own life if returned, again notwithstanding her acknowledgement of protective factors. She has not lived with her children now for a considerable period of time and reintegrating into their lives will, to say the least, self-evidently be a difficult undertaking.
103. In light of what we have said above, and on the evidence as a whole, we find that the risk of suicide on return to Ghana would remain “high” despite the existence of protective factors.
104. There is then the sixth question in J v SSHD, namely the availability of appropriate treatment as a mitigating factor against the risk of suicide. We are entitled to assume that the respondent would put in place measures in order to monitor the appellant during the removal process itself: J v SSHD, at [57]-[62].
105. We have already found that appropriate treatment is available and accessible to the appellant on return to Ghana, albeit at a cost and involving significant sacrifices by her family members in that country. We take account of the evidence of Dr Chishti and Dr Ali that maintaining the appropriate treatment regime is crucial in order to avoid, or at least reduce, the risk of significant and rapid deterioration in the appellant’s mental health.
106. In so far as medical treatment might materially reduce the risk of suicide, we take account of the following considerations. First, everything we have said so far about the appellant’s subjective fears (albeit not well-founded), her categorical statements of intent if she were sent to Ghana, her significant problems even whilst in United Kingdom, and the nature of her cognitive and mental health conditions (current command hallucinations despite being in receipt of appropriate treatment in the United Kingdom) must be borne in mind. Secondly, it is apparent that the treatment regime following return would not represent continuous, supervised monitoring of suicide risk. Given what we know about the current monitoring and the likely need for (at least partial) private funding of treatment, it would at most involve monitoring appointments once every two months, together with the appropriate prescribing of medication. The appellant’s sons are not medically trained and cannot be expected to conduct their own continuous supervision (given their need to work). Thirdly, the respondent has never suggested that the appellant could/should be sectioned (or its equivalent in Ghana) in order to reduce the risk of suicide. In any event, our previous and subsequent conclusions on the accessibility of appropriate medical treatment are relatively finely balanced. It is, we find, extremely unlikely that the appellant’s family members would be able to afford the extra funds highly likely to be required for in-patient care, even if it were available (which, on the country evidence, seems very doubtful).
107. We now bring all of the foregoing together, having considered everything on a cumulative basis. We reiterate two important aspects of the legal framework: the burden rests on the appellant and we are concerned this stage with a threshold question, not a requirement to provide “clear proof” of a violation of Article 3.
108. Overall, we are satisfied that, on the particular facts of this case, the appellant has adduced evidence capable of demonstrating that substantial grounds have been shown for believing that as a seriously ill person, the appellant would face a real risk of a completed act of suicide if returned to Ghana. In short, on this particular issue in her appeal, the appellant has satisfied the demanding threshold test as set out by the Supreme Court in AM (Zimbabwe) and summarised by the UT in its decision on remitted appeal.
109. That is not the end of the matter. Our conclusions on the threshold test mean that the focus now shifts to the respondent in respect of her obligations under Article 3: Savran, at [135]. In THTN v SSHD [2023] EWCA Civ 1222, the Court of Appeal said the following in connection with the procedural aspect of Article 3 medical cases and the initial threshold test:
“51. In the real world, the SSHD in a case such as this would be almost certain to adduce country information evidence in anticipation of the F-TT’s consideration of the issue. In the unlikely event that for some excusable reason such evidence had not been adduced, the F-TT would be likely to give the SSHD an opportunity to remedy the position.”
110. Our starting point is that the respondent is expected to bring all of her case (including appropriate evidence) to the appellate table at the first opportunity. In the present case, means the hearing before us. In the event, the respondent has relied on her CPIN and nothing else.
111. We have considered whether it is appropriate to give the respondent a further opportunity to adduce evidence in light of our conclusion on the threshold test. The appellant’s case has involved a number of elements. As regards Article 3, there were two: suicide risk and a more general absence of accessible medical treatment. The respondent was of course unable to anticipate in advance which of these two, if either, would result in a conclusion favourable to the appellant. We also note that the appellant has relied on new evidence before us which was provided to the respondent relatively late in the day. The respondent’s review was prepared at a point in time when the respondent did not have sight of the new evidence. Whilst we are cautious in taking this step, given what is said in THTN, we conclude that procedural fairness requires us to provide the respondent with an opportunity to adduce further evidence.
112. We will issue relevant directions at the end of our decision.
Issue 2: Conclusions on the availability and accessibility of appropriate medical treatment in Ghana
113. We can state our conclusions on Issue 2 relatively briefly. For the avoidance of any doubt, these are distinct from our conclusions on Issue 1. We transpose our findings of primary facts, as set out at [32]-[88] above, to the question of whether the appellant has satisfied the demanding threshold test in respect of the availability and accessibility of appropriate medical treatment in Ghana.
114. We harbour certain reservations about the longer-term sustainability of the appellant’s situation in Ghana. However, the threshold test is demanding and in light of our findings of fact, we conclude, by relatively narrow margin, that the appellant has failed to adduce evidence capable of demonstrating substantial grounds for believing that she would face a real risk of a serious, rapid, and irreversible decline in her state of health resulting in intense suffering by virtue of the absence of or lack of access to appropriate medical treatment in Ghana. Specifically, we find that the appellant has failed to adduce evidence capable of demonstrating substantial grounds for believing she would face a real risk of being unable to obtain appropriate medication in Ghana and the same is true in respect of appropriate monitoring.
Issue 3: Conclusions on paragraph 276ADE(1)(vi) of the Rules
115. Both parties agree that the appropriate provision for us to consider in this appeal is paragraph 276ADE(1)(vi) because it was in force at the time of the respondent’s decision back in 2021.
116. If that is correct, the appellant faces an obstacle. Paragraph 276ADE(1) begins with a time-fixed condition, namely that the applicant must satisfy the relevant requirements as “at the date of application”. In the appellant’s case, the application (by way of further submissions) was made on 24 March 2020. At that point in time, the appellant had accrued an NHS debt. Therefore, S-LTR. 4.5 of the suitability provisions under Appendix FM to the Rules applied to her situation and this constituted a discretionary ground for refusing the application under paragraph 276ADE(1)(i): [22] and [23] of the reasons for refusal letter.
117. The NHS debt was not cancelled by the respondent until 24 September 2024. This means that the suitability ground applied to the appellant’s case in 2020.
118. On the appellant’s Behalf, Mr Bazini submitted that the respondent should have exercised discretion in relation to the suitability ground, but had failed to consider this. There had been no consideration of the respondent’s guidance at the time, which required caseworkers to consider whether there were compassionate or other circumstances when considering discretion. Mr Bazini emphasised the appellant’s circumstances: she was the victim of a hit-and-run accident, had sustained significant life changing injuries, and was unable to work thereafter and therefore unable to repay the debt.
119. There is considerable force in Mr Bazini’s submission on this particular point. There is no indication that the respondent considered her discretion when refusing the appellant’s claim in 2021, at least in respect of the NHS debt and suitability. In our view, there were clearly compassionate circumstances then in existence which would have gone to the exercise of discretion, namely the accident and consequent inability to repay that it. The cancellation of the NHS debt in September 2024 is indicative of the respondent’s own acknowledgement of compassionate circumstances at that point and it is difficult to see why the very same circumstances were not considered at the time of the refusal. Taking these matters into account, we conclude that discretion should have been exercised in the appellant’s favour.
120. As to the existence of very significant obstacles to (re)integration, the relevant authorities, including Kamara v SSHD and NC v SSHD, require a broad evaluative judgment to be made as to whether the individual will be enough of an insider to be able to integrate in the society in which they will be living, enjoy a capacity to participate in it in order to have a reasonable opportunity to be accepted, to establish human relationships, and have a private and/or family life which is of at least some substance. That test is a practical one, which must take account of the reality likely to be faced by the individual.
121. Based on the following considerations, we conclude that such obstacles did exist in March 2020. The respondent has not contended that the appellant did not have significant cognitive and mental health problems at that point and we find that she did. It is highly likely that her memory and other functional abilities were significantly reduced, with the consequences of this for her ability to live a reasonable life. Dr Chishti has concluded that the cognitive difficulties faced are “unlikely to improve”. He has concluded that the appellant is unfit to give evidence as a consequence of her significantly impaired short-term memory. Whilst on return the question of giving evidence at a hearing does not of course arise, the memory problems must surely be relevant to her ability to function on a day-to-day basis in society. We take account of the fact that the appellant currently rarely leaves the house because of the command hallucinations and her subjective fears, and that she feels unable to express herself in public due to memory problems. Those problems would, in the opinion of Dr Chishti, result in “challenges familiarising herself with the environment [in Ghana]”. It has not been suggested by the respondent that the appellant did not have these problems in March 2020, and we find that they did all apply.
122. In respect of Dr Ali’s report, the cognitive deficits (in particular memory loss) are highlighted and the appellant is described as “just existing” in the United Kingdom and that she often forgets to undertake basic self-care. Even taking account of support of her sons, it is very likely that the appellant’s ability to self-care would at best have only slightly improved if she were in Ghana. Again, the respondent has not suggested that these difficulties did not exist back in 2020, and we find that they did.
123. We take account of what we have already said in respect of the Article 3 medical aspect of the appellant’s case, whilst reminding ourselves that Article 8 is not an alternative backdoor means of succeeding on medical grounds. We are satisfied that she was unable to work in the United Kingdom and would have been unable to work if in Ghana. Her cognitive and mental health problems would, we find, have prevented her from establishing any meaningful relationships outside those with her three sons. She had at that point of being away from Ghana for approximately nine years. Seven of those years came after the accident and it is likely that a sense of disassociation from a previous life in Ghana can only have been enhanced and entrenched by her consequent significant difficulties. We take into account her genuinely-held subjective fears of a return to Ghana We take into account country information which indicates that there is societal stigmatisation against those with mental health conditions: for example, the US State Department human rights report contains the following passage:
“Persons with both mental and physical disabilities, including children, were frequently subjected to abuse and tolerance. Authorities did not regularly investigate and punish violence and abuses against persons with disabilities.”
124. That picture is replicated in other sources relied on by the appellant. In addition, Dr Iwilade’s report, which has not been of great assistance in respect of the issue of medical treatment, does provide (unchallenged) evidence on the question of societal attitudes towards those with mental health conditions. He describes “high levels of stigma, abuse and discrimination that people with mental health challenges face.” In the appellant’s case, her psychosis has manifested itself in ways which we find make it more likely that she would have been readily identifiable by the community as being unwell.
125. Aside from the consequences of her accident in 2013, there would have been no very significant obstacles, but the changes brought about by what happened to her in this country entirely changed the position. All-told, it is more likely than not that she would not have been considered an insider by those around her, she would not have been able to reasonably function on a day-to-day basis, and would not have been able to establish any meaningful relationships or a private life of any substance.
126. In the alternative to the application of paragraph 276ADE(1), if we were to consider the provisions of Appendix Private Life as of now (whether that is because the historic paragraph 276ADE(1) is not the applicable provision or on the basis that the appellant made a private life application now), there is no time-fixed stipulation and no suitability issue arises. In light of what we have said at [121] and [125] above and as they relate to the current position, we have no doubt that the appellant would face very significant obstacles to integration if returned to Ghana. Her ability to function within society in this country is severely restricted, and we are satisfied that her practical and social functionality would, if anything, be more pronounced in Ghana. In saying that, we regard the integration test as representing an individual’s existence within society and not simply within the four walls of a family home. Expecting or requiring an individual to remain confined would itself represent a very significant obstacle to integration. In any event, the severely impeded functional abilities of the appellant would represent very significant obstacles to integration within society at large. Indeed, we can properly describe those obstacles as being very very significant.
127. In summary, we conclude that the appellant satisfies the Rules as at the date of her application (further submissions) and/or as of today, and she is therefore entitled to succeed in her appeal on Article 8 grounds: TZ (Pakistan) v SSHD [2018] EWCA Civ 1109.
Issue 4: Conclusions on Article 8 outside of Rules
128. If we were wrong in our conclusion on the application of paragraph 276ADE(1) as at March 2020 and if we were precluded from considering Appendix Private Life as at the date of hearing, we would nonetheless conclude that the appellant’s removal to Ghana would be disproportionate. This is based on the following considerations, all of which are to be seen in light of section 117B NIAA 2002, the applicable authorities, and predicated on the undisputed fact that she has established a private life in this country and that removal would constitute a sufficiently serious interference with that life.
129. The respondent can clearly rely on the need to maintain effective immigration control: section 117B(1). The appellant has been in the United Kingdom unlawfully since 2011. This is a weighty factor in favour of the proportionality of removal.
130. That unlawful status would ordinarily mean that “little weight” is to be attributed to the appellant’s private life: section 117B(4). There is, however some flexibility in the application of section 117B(4): Rhuppiah v SSHD [2018] UKSC 58. Her current circumstances arose from a tragic accident and were clearly not the fault of the appellant. The consequences of the accident have had a drastic impact on her life. We conclude that this consideration, which we find to be an unusual and compelling feature of the case, permits us to place more than simply “little weight” on her private life.
131. The appellant’s inability to satisfy the Rules (in this alternative scenario) carries considerable weight in the respondent’s favour: Agyarko v SSHD.
132. The appellant has been in this country for a considerable period of time, albeit the great majority of this without any status. Whilst relevant, this particular point does not carry much weight.
133. Our conclusion that she would face “very very” significant obstacles to integration stands for the purposes of the balancing exercise, even if she is unable to meet the Rules. The substance of the very significant obstacles is wide-ranging and would cover all aspects of the appellant’s existence in Ghana.
134. We are satisfied that the appellant speaks good English. That is a neutral consideration.
135. As to reliance on public funds, NHS treatment counts against her in the balancing exercise. Having said that, the debt previously accrued was cancelled by the respondent in September 2024. We have not been provided with a specific reason for this, but the respondent’s decision would tend to indicate a recognition that the applicant was in a precarious health and financial position which justified the cancellation of what must have been a considerable sum of money. We take this into account.
136. Overall, we conclude that there are exceptional circumstances in her case and these tip the balance in the appellant’s favour. Her protected rights outweigh the strong public interest in maintaining immigration control.
Anonymity
137. There has never been an anonymity direction in this case and there is no basis on which one should now be made.
Notice of Decision
The making of the decision of the First-tier Tribunal did involve the making of an error on a point of law and that decision has been set aside.
Issue 1: The appellant has met the applicable Article 3 threshold in respect of the risk of a completed act of suicide. That does not of itself result in her appeal being allowed on Article 3 grounds. This aspect of the appellant’s appeal remains open and subject to the directions set out below.
Issue 2: The appellant has failed to meet the applicable Article 3 threshold in respect of the availability and accessibility of appropriate medical treatment. Her appeal fails in respect of Issue 2.
Issue 3: The appellant satisfies the relevant Immigration Rules and her appeal is allowed on Article 8 grounds.
Issue 4: The appellant’s removal from the United Kingdom would represent a disproportionate interference with her right to respect for private life and her appeal is allowed on Article 8 grounds.
Directions
(1) No later than 14 days after this decision is sent out to the parties, the respondent shall confirm in writing by e-filing with the Upper Tribunal and email service on the appellant:
(a) Whether the appellant’s appeal in respect of Issue 1 (suicide risk) is now conceded; or
(b) Whether the respondent continues to oppose the appeal in respect of Issue 1 and wishes to adduce further evidence in light of the Tribunal’s conclusions on the threshold test and whether she is content for Issue 1 to be finally determined without a further hearing.
(2) If (1)(a) applies, the respondent shall at the same time confirm that she is content for the Tribunal to allow the appellant’s appeal in respect of Issue 1 without a further hearing;
(3) No later than 7 days after receipt of the respondent’s confirmation, the appellant shall file and serve a response;
(4) Following compliance with the above directions, or in default, the Tribunal will either send out a further decision notice addressing Issue 1, or issue further case management directions, as appropriate;
(5) The parties may apply to vary the above directions, marking any such application for the urgent attention of Upper Tribunal Judge Norton-Taylor and copying in the other side.
H Norton-Taylor
Judge of the Upper Tribunal
Immigration and Asylum Chamber
Dated: 26 January 2026