Tribunal decisions

The decision

IN THE UPPER TRIBUNAL
IMMIGRATION AND ASYLUM CHAMBER
Case No: UI-2025-000087

First-tier Tribunal No:
HU/54122/2023
LH/04112/2024

THE IMMIGRATION ACTS

Decision & Reasons Issued:
On 17 October 2025

Before

UPPER TRIBUNAL JUDGE RUDDICK

Between

Muhammad Ilyas Butt
Appellant
and

SECRETARY OF STATE FOR THE HOME DEPARTMENT
Respondent

Representation:
For the Appellant: Mr D. Bazzini, instructed by Legafit Solicitors
For the Respondent: Ms S. McKenzie, Senior Home Office Presenting Officer

Heard at Field House on 29 September 2025

DECISION AND REASONS
1. This decision is the remaking, under section 12 (2) (b) (ii) of the Tribunals, Courts and Enforcement Act 2007, of a First-tier Tribunal (“FTT”) decision dated 21 September 2024 but set aside in part by the Upper Tribunal in a decision promulgated on 16 June 2025.
2. The appellant is a citizen of Pakistan born in January 1954. It is not in dispute that the is widowed and all of his five children live outside Pakistan. Nor is it in dispute that he suffers from a number of complex medical conditions (Ischemic Heart Disease, Diabetes Mellitus, Angina, Adjustment Disorder, Anxiety, Depressive Disorder and poor mobility due to back pain) and that as a result he requires long-term personal care to perform everyday tasks.
3. On 16 December 2022, the appellant applied for entry clearance to the UK as the adult dependent relative of his son, Saqib Ilyas Butt, who is settled in the UK. The application was made under the Adult Dependent Relative section of Appendix FM; the current version of these rules is now found in Appendix Adult Dependent Relative.
4. It is accepted that the appellant meets all of the requirements of the rules under which he applied, with the exception of E-ECDR 2.5:
“The applicant […] must be unable, even with the practical and financial help of the sponsor, to obtain the required level of care in the country where they are living, because-
(a) it is not available and there is no person in that country who can reasonably
provide it; or
(b) it is not affordable.”
5. The appellant has now submitted up-to-date evidence that he says shows that he meets this requirement of the rule as well, because the treatment that he requires is simply not available in Pakistan. The respondent, in turn, relies on evidence that she says shows the opposite.
The hearing
6. The hearing was delayed by the respondent’s failure to provide Ms McKenzie with the appellant’s composite bundle for the remaking hearing, filed with the Upper Tribunal in accordance with directions on 5 August 2025. This was regrettable, as Mr Bazzini was able to confirm that the bundle had been served on the respondent on 14 August 2025 in three separate parts (an email of 5 August 2025 to which the complete bundle had been attached had bounced back). I identified the new evidence as that contained at pages 56-118 of the appellant’s composite bundle and I rose to allow time for Ms McKenzie to be provided with it. Ms McKenzie then asked for time to read the new evidence, which was agreed. Once she had confirmed that she was ready to proceed, the hearing proceeded by submissions only.
7. I heard first from Ms McKenzie. She relied on sections “9. Geriatrics” and portions of section “21. Sheltered housing, care homes and carer support” of the respondent’s Country Information Note (“CIN”), Pakistan: Healthcare and medical treatments, Version 3.0 (July 2024) as showing that the required care was available.
8. She then addressed the appellant’s new evidence, submitting that it was not inconsistent with the respondent’s position, because it mainly addressed the inadequacy of government-funded care. She said she had taken into account the updating medical reports and that the type of care the appellant was identified as needing could be obtained privately, as documented in the sections of the CIN she had taken me to.
9. Mr Bazzini then took me to the previous findings about the appellant’s medical needs and his updating evidence. He stressed that the question was not whether any care was available in Pakistan; the appellant accepted that there was some care available. The question was whether care was available that met what was required by this particular applicant. He urged me to find on the basis of the independent evidence that it was not.
10. At the end of the hearing, I reserved my decision, which I now give with my reasons.
Legal framework
Family life between adult relatives
11. The appellant appeals under section 82(1)(b) and 84(2) of the Nationality, Immigration and Asylum Act 2002, on the grounds that the respondent’s refusal of his human rights claim is unlawful under section 6 of the Human Rights Act 1988. He says this can be inferred from the fact that he meets the Immigration Rules under which he applied for entry clearance, namely section Adult Dependent Relative of Appendix FM. As established in TZ (Pakistan) v SSHD [2018] EWCA Civ 1109 at [34]:
“where a person satisfies the Rules, whether or not by reference to an article 8 informed requirement, then this will be positively determinative of that person's article 8 appeal, provided their case engages article 8(1)”.
12. As noted above, the parties agreed that the central question before me was whether the appellant is “unable, even with the practical and financial help of the sponsor, to obtain the required level of care” in Pakistan because either “(a) it is not available and there is no person in that country who can reasonably provide it”; or (b) it is not affordable.” Although that may be the only issue with regard to the appellant’s ability to meet the rules, in accordance with TZ (Pakistan), I must still find that article 8(1) is engaged. This cannot be presumed: BRITCITS v The Secretary of State for the Home Department [2017] EWCA Civ 368 at [74].
13. As the family life in question is between the appellant and his adult son, the framework for deciding whether family life exists is set out in Kugathas v SSHD [2003] EWCA Civ 31 and a long line of subsequent caselaw. In summary, there is no presumption either for or against the existence of family life between adult children and their parents: Singh v SSHD [2015] EWCA Civ 630 (“Singh 2”) at [24]. Each case must be decided on its own facts, with the burden being on appellants to establish the facts on which they rely. In Mobeen v Secretary of State for the Home Department [2021] EWCA Civ 886, Lady Justice Carr (with whom Baker LJ and Underhill LJ agreed) summarised the established principles as follows:
“45. Whether or not family life exists is a fact-sensitive enquiry which requires a careful assessment of all the relevant facts in the round. Thus it is important not to be overly prescriptive as to what is required and comparison with the outcomes on the facts in different cases is unlikely to be of any material assistance.
“46. However, the case law establishes clearly that love and affection between family members are not of themselves sufficient. There has to be something more. Normal emotional ties will not usually be enough; further elements of emotional and/or financial dependency are necessary, albeit that there is no requirement to prove exceptional dependency. The formal relationship(s) between the relevant parties will be relevant, although ultimately it is the substance and not the form of the relationship(s) that matters. The existence of effective, real or committed support is an indicator of family life. Co-habitation is generally a strong pointer towards the existence of family life. The extent and nature of any support from other family members will be relevant, as will the existence of any relevant cultural or social traditions. Indeed, in a case where the focus is on the parent, the issue is the extent of the dependency of the older relative on the younger ones in the UK and whether or not that dependency creates something more than the normal emotional ties.
“47. The ultimate question has been described as being whether or not this is a case of "effective, real or committed support" (see AU [AU v SSHD [2020] EWCA Civ 338] at [40]) or whether there is "the real existence in practice of close personal ties" (see Singh 1 [Singh v ECO New Delhi [2004] EWCA Civ 1075] at [20]).
The adult dependent relative rules
14. As set out above, it is accepted that the appellant meets all of the requirements of the rules other than Para. E-ECDR.2.5. He says that he meets this requirement as well because the care he requires is not available. As to what the “required level of care” is, it was agreed before me that the relevant standard is that set by the rules. It is “long term personal care to perform everyday tasks”. Any more precise definition will depend on the medical evidence in each particular case.
15. As Mr Bazzini rightly submitted, the leading case on the “required level of care” is BRITCITS. It established:
“the focus is on whether the care required by the ADR applicant can be “reasonably” provided and to “the required level” in their home country. […] the provision of care in the home country must be reasonable both from the perspective of the provider and the perspective of the applicant, and the standard of such care must be what is required for that particular applicant. It is possible that insufficient attention has been paid in the past to these considerations, which focus on what care is both necessary and reasonable for the applicant to receive in their home country. Those considerations include issues as to the accessibility and geographical location of the provision of care and the standard of care. They are capable of embracing emotional and psychological requirements verified by expert medical evidence. What is reasonable is, of course, to be objectively assessed.” [59]
“rejection on the basis of the availability of adequate care in the ADR’s home country turns upon whether the care which is available is reasonable for the ADR to receive and of the level required for that applicant. Contrary to the submission of the appellant, those considerations are capable, with appropriate evidence, of embracing the psychological and emotional needs of elderly parents.” [76]

16. The respondent’s current published guidance, Family Policy: Adult dependent relatives, Version 6.0 (16 July 2025), is broadly in line with BRITCITS:
“The “required level of care” is a matter to be objectively assessed, with reference to the specific needs of the applicant. The level of long-term personal care must be what is required by the individual applicant to perform everyday tasks, in light of their physical needs and any emotional or psychological needs, in each case as established by evidence provided by a doctor or other health professional […]
“The provision of the care in the applicant’s home country must be reasonable both from the perspective of the provider of the care and the perspective of the applicant.
“The ECO should bear in mind any relevant cultural factors, such as in countries where women are unlikely to be able to provide support in some circumstances.”
Discussion and findings
17. I find that there is family life between the appellant and his sponsor. As I did not hear from the appellant’s family, I make my decision on the basis of the documentary and expert evidence, none of which has been challenged by the respondent.
18. In accordance with the caselaw, in assessing whether there is family life, I have taken into account the cumulative effect of a range of factors.
19. The appellant has no close family in Pakistan. He was widowed in 2016, and all of the expert reports describe him as lonely and isolated. Although the lack of other social relationships in Pakistan would, on its own, be insufficient to establish family, it was identified as a relevant factor in Mobeen at [46]. I consider that it is reasonably likely that it contributes to the appellant’s dependence on the sponsor.
20. In July 2025, Tahmina Yasser, a Senior Clinical Psychologist, assessed the appellant over the course of four home visits. She described the appellant’s declining mental health as directly linked to the loss of his wife in 2016 followed by the emigration of his children. I infer from this that the appellant had depended on his children for his emotional wellbeing prior to their departure and consider that this makes it more plausible that he continues to depend on them emotionally now.
21. The evidence from the appellant’s treating psychologist, Dr Maahin Rizwan, repeatedly refers to the appellant’s emotional bond with his children, including the sponsor. It also documents a direct correlation between contact with his family and the appellant’s mental and physical health. In July 2024, Dr Rizwan wrote that the appellant had lived with his children until they emigrated and that he “is always happier and confident when he is around his children”. It was recorded that he responded positively to video calls where he could “physically see” his children and grandchildren and it was “essential” that the calls continue.
22. I also find that the medical evidence indicates that the appellant relies on his son in order to fully engage with medical care – particularly mental health care – and social support. Dr Rizwan notes in the July 2024 report that the appellant would not engage with mental health therapy because he saw it as “against his pride and principles” and that for this reason the assessment was “only possible due to his son is present with him”. In July 2025, Dr Rizwan further noted that the appellant’s appetite, medication and dietary adherence and general health all improved during visits from either the sponsor or his daughter (the sponsor’s sister). He was “more expressive and compliant in sessions after family video call” and there was “improved grooming, effect and verbalization following family interaction”.
23. I also have a care assessment prepared in July 2024 by Plan Care Services, an organisation registered with and regulated by Social Care Wales. The assessment was based on the medical evidence and a Teams assessment with the appellant, the sponsor and his daughter Momina. The social worker preparing the report noted that the sponsor was visiting his father at the time, and that the appellant “struggled to speak directly to me and instead spoke through his son”. In her conclusion, the social worker wrote that the appellant would be “more likely to engage with professionals who offer support” if his family were present.
24. I find on the basis of this medical evidence that the appellant’s mental and physical health depends significantly on his relationship with the sponsor.
25. In addition, the sponsor has consistently provided the appellant with a level of financial support that represents a significant portion of his income. In support of the application, the unchallenged evidence showed that the sponsor’s taxable income was just under £42,000 in the last tax year, and that he had sent his father almost £19,000 over the preceding 13 months. This is a significant commitment on the sponsor’s part, particularly in light of the fact that he has four children of his own to support. The sponsor also owns the property in which his father has lived since 2010.
26. Finally, the expert evidence refers repeatedly to the dominant cultural and social traditions in Pakistan which dictate that elderly parents are cared for by their children. This is likely to contribute to the sponsor’s commitment to his father, and to his father’s willingness to depend on him and refusal to accept help from others.
27. For these reasons, I find that there are additional elements of dependency and real, effective and committed support between the sponsor and his father, and that article 8(1) is engaged.

The appellant’s care needs
28. As noted above, it is accepted that the appellant requires long-term personal care to perform everyday tasks, but there has been no specific acceptance of what level of care he requires.
29. I begin my assessment of the appellant’s current care needs by taking into account the preserved findings of the FTT, set out at [9] of the decision below:

“I have considered all of the different medical reports both physical and mental, and it is clear the Appellant is declining. The Appellant has had unsuccessful home carers who are not reliable at attending, come late, one has stolen some of his belongings, and the Appellant has become very fearful and it was submitted that a significant contribution to his mental distress is from his experiences from the home help/carers. I accept the Appellant is vulnerable now that he is widowed and his children have all left home and the country leaving him behind. The Appellant talks daily with the family but they are not there all of the time to supervise the sporadic care. The Appellant has multiple health issues which have worsened over the years and he has multiple care needs which is accepted by the Respondent.”
30. I had before me updating medical evidence, consisting of: a report dated 21 July 2025 from the appellant’s GP, Adbul Raheem, who has been treating the appellant for nine years; the reports from Dr Rizwan, who has met with the appellant eight times since September 2022; the psychological assessment of Ms Yasser; and hospital records from January-February 2025, documenting the appellant’s admission to hospital in January 2025 for cardiac related symptoms. In summary it appears that in January 2025, the appellant was admitted to hospital on an urgent basis. An angiogram showed “severe triple vessel disease”, this was managed “conservatively” and he was discharged. His “overall medical condition” was noted to have “deteriorated since his last visit”.
31. The respondent has not challenged any of the medical evidence, and I note that the authors all set out their professional credentials, which are impressive. The reports are detailed and professional in their tone and content. To a lay reader, their conclusions appear well-reasoned and based in the evidence. They are entirely consistent with each other, although written from different professional perspectives. I therefore accept that they are more likely than not to be reliable and I place considerable weight on them.
32. I find on the basis of this evidence that the appellant’s care needs are complex, because of the interaction of his mental ill health, his multiple serious chronic illnesses and the physical disabilities related to those illnesses. There are multiple references in the expert evidence to the appellant’s inability to trust outside carers, which helps explain the close link between his mental health and the difficulty in meeting his personal care needs. This lack of trust is not simply a result of the documented instances of theft he suffered. Ms Yasser diagnosed him with a major depressive disorder and generalized anxiety disorder but also noted symptoms of paranoia. A letter from Plan Care Home Nursing Services dated 14 July 2025 noted the appellant’s “minor dementia, emotional instability, and periodic episodes of aggression” in their letter explaining why they could not provide him with appropriate home care. As noted above, Dr Rizwan’s reports record the appellant’s non-adherence with his medication, weight loss and lack of engagement with treatment, all linked to his mental ill health as well as to his cognitive decline. The consensus is that he needs an integrated care plan to manage his multiple and inter-related physical and mental health conditions. In addition, due to seriousness of his physical health conditions, that care needs to involve some degree of specialist oversight and monitoring, in order to respond to emergencies.
33. I accept the GP’s summary as accurate:
“There is a pronounced interplay between Mr Butt’s physical health and mental well-being. His chronic medical conditions – including diabetes, cardiovascular disease, and joint degeneration – are contributing factors to his emotional distress and functional decline.
“Simultaneously, his depression and cognitive impairment reduce his ability to manage his health proactively, leading to suboptimal treatment adherence and increased risk of hospitalization. The lack of emotional support and human interaction has a compounding negative effect on both his physical resilience and psychological coping mechanisms.
“A care approach that integrates mental and physical health management within a supportive, familiar environment is essential to halt further deterioration and improve overall well-being.”
Whether the required level of care is available in Pakistan
34. The appellant relies on an expert report from Prof Uzma Ashiq, the Chairperson of the Department of Social Work at the University of the Punjab. She has over 20 years of professional experience, which is set out across 14 pages. She has published papers on a range of topics, including more than ten on geriatric issues. She provides a page of references that informed her report, which were all published in the last five years and are from reliable sources, such as the WHO, the Pakistan Journal of Public Health, and the Oxford Institute of Population Ageing. I place considerable weight on her report. Ms McKenzie submitted at the hearing before me that Dr Ashiq’s report dealt only with government-provided care. That is simply not the case.
35. I do not reproduce all of Dr Ashiq’s opinions here. The ones that I consider particularly relevant are:
(i) “A common thread across all care home types is the exclusion of elderly individuals with mental health conditions”.
(ii) Private care homes “are not equipped to manage residents with psychiatric illnesses, behavioural disorders, or severe chronic medical conditions. This is largely due to limitation in trained staff, inadequate medical infrastructure, and liability concerns.”
(iii) “A large number of caregivers employed by home care agencies are not formally certified in nursing, geriatrics, or first aid. Many are domestic workers with no healthcare background. [… They are] frequently unable to respondent appropriately to emergencies, such as strokes, falls or psychiatric episodes […]”
(iv) “Agencies primarily focus on physical assistance, ignoring emotional and cognitive support.”
36. I also accept Ms Bazzini’s submission that the opinions of the appellant’s treating GP and psychiatrist about what care options are available are worthy of some weight. As active medical practitioners, it is to be expected that they would have professional knowledge and experience of where they can (and cannot) refer their patients. Dr Raheem’s opinion is that the appellant’s needs go “beyond what general caregiving or untrained domestic help can provide” and that institutionalization would pose significant medical and emotional risk due to the limited ability to care for residents with complex conditions. Dr Rizwan agrees that no existing institution can be recommended due to the appellant’s complex needs.
37. The appellant further relies on a letter from PlanCare Home Nursing Services, confirming following an assessment of the appellant that they cannot provide the care he needs. They also state that they are unaware of any residential facility or home care provider that could provide that care. A letter from the Assistant Director of the government run Old Age Home Lahore states that they could not accommodate the appellant due the severity of his physical problems and “his mental instability”. She also expresses the opinion that “there are not care or residential home available which are designed to meet these kinds of needs”.
38. The respondent relies on her CIN in Pakistan in support of the view that care would be available. The evidence Ms McKenzie took me to was the following:
9. Geriatrics
9.1 Physical therapy, assistance, and medical orthopaedic devices
9.1.1 According to the Aga Khan University Hospital, it provided health consultations for people aged 60 and over and home health services that are ‘… designed to make quality medical care more easily accessible, comfortable and convenient for people who are elderly, chronically ill, living with incurable diseases, recovering from surgery, disabled or need specialised care.’
9.1.2 The same source added that services included:
• ‘Long stay home care
• ‘Home nursing short procedures
• ‘Home physician consultation
• ‘Home physiotherapy
• ‘Medical equipment either for purchase or to rent.’
9.1.3 The Shifa International Hospital noted its geriatric care services ‘… serves the health and wellness needs of adults at the age of 65 years and older. Anyone in this age range can receive primary care in our patient-centered medical home. However, our team is best suited to provide care for people who are:
• ‘85 years and older
• ‘Have functional or cognitive limitations, or
• ‘Multiple, chronic medical conditions.’
9.1.4 A MedCOI response in May 2020 noted that the following treatments and procedures were available at the Aga Khan University Hospital, Stadium Road, Karachi and the Shifa International Hospital H-8, Islamabad, both private facilities:
• ‘Inpatient, outpatient and follow-up by a physical therapist.’
• ‘medical devices orthopaedics: walking aid such as a walker or a cane
• ‘home assistance / care at home by a nurse.’
21. Sheltered housing, care homes and carer support
[…]
21.1.2 A 2019 MedCOI noted that geriatric care, psychiatric treatment (including for chronic psychotic patients), and long- term institutional around the clock care in sheltered housing was available at:
• ‘Edhi Homes, Sohrab Goth, Karachi (private facility).’
21.1.3 The Holistic healthcare Services, a private company based in Lahore, stated provision of care for relatives at home in Pakistan included:
• Physiotherapy
• Speech and Occupational Therapy (See speech therapy)
• Assistant nurses
• Caregivers
• ICU (Intensive care unit) trained nurses
• Medical attendants
• Psychotherapists
• General Physicians
• Disabled care
Located at: Lahore, Islamabad, Faisalabad and Karachi
39. I consider that this evidence does little to establish that the long-term care the appellant needs is available, contrary to the views expressed by the various professionals, which I have cited above. In the first place, where the source of the evidence is given, it is the website of the named provider. These are promotional materials and although there is no reason to believe that they are actively misleading, they are not impartial and they are written at a general level. Moreover, the Aga Khan University Hospital and Shifa International Hospital webpages relied on contain no reference to offering mental health care. The Holistic Healthcare Services website provides little detail of what care they provide in the home, and the hyperlinks that would appear to lead to more specific information revert to the home page. It is worthy of very little weight as evidence that they could meet this appellant’s complex care needs. The references to “MEDCOI”, finally, are of little assistance, as their evidentiary basis is entirely unclear and they are more than five years out of date.
40. I therefore conclude that the appellant has established that, given his range of physical and mental health conditions and the interaction between them, the care he needs is not available in Pakistan. This is the unanimous and reliable view of a range of well-qualified experts.
41. Because article 8(1) is engaged and the appellant meets all of the requirements of the rule under which he applied, the appeal falls to be allowed, in line with TZ (Pakistan).

Notice of Decision
The appeal is allowed.

E. Ruddick

Judge of the Upper Tribunal
Immigration and Asylum Chamber

3 October 2025