Tribunal decisions

The decision

IN THE UPPER TRIBUNAL
IMMIGRATION AND ASYLUM CHAMBER Case No: UI-2025-003694
(HU/51749/2024)
(LH/07238/2024)

THE IMMIGRATION ACTS

Decision & Reasons Issued:
On 23 March 2026

Before

UPPER TRIBUNAL JUDGE KEBEDE
DEPUTY UPPER TRIBUNAL JUDGE ALIS

Between

MS ZAHIDA NASREEN
(NO ANONYMITY ORDER MADE)
Appellant
AND

SECRETARY OF STATE FOR THE HOME DEPARTMENT
Respondent

Representation:

For the Appellant: Mr Grigg, Counsel instructed by MCR Solicitors
For the Respondent: Mr McVeety, Senior Home Office Presenting Officer
Interpreter: Ms Amir

Heard at Manchester Civil Justice Centre on the 9 March 2026

DECISION AND REASONS

1. The Appellant is a national of Pakistan and is 68 years of age. She appealed against the Respondent’s decision to refuse to grant her entry clearance as an adult dependant under Appendix ADR of the Immigration Rules.

BACKGROUND AND MATTERS IN ISSUE
2. By its decision dated 8 July 2025 the First-tier Tribunal (FtT) dismissed her appeal. Whilst the FtT accepted Appendix ADR 5.1 of the Immigration Rules was met it did not accept the Appellant met the requirements of Appendix ADR 5.2 of the Immigration Rules. The FtT further found the Appellant did not enjoy family life with the Sponsor and her other family in the United Kingdom and accordingly it was not necessary to consider whether there were any exceptional or compassionate circumstances under article 8 ECHR.
3. The Appellant appealed this decision and Tribunal Judge Nightingale granted permission to appeal to the Upper Tribunal on 12 August 2025 stating:
“3. The Judge finds that Article 8 family life is not established in this case (§87). At §84 the Judge accepts that there have been visits, that the Sponsor and her family send financial support and that they provide comfort through the contact that takes place, however the Judge finds that this is insufficient to demonstrate family life. The Judge has erred in finding no family life and has applied too high a test (Ghising (family life – adults - Gurkha policy) Nepal [2012] UKUT 160 (IAC) (11 April 2012)).
4. It was not for the Judge to state why care would be affordable in Pakistan but, rather, for the appellant to establish on balance that it was unavailable or, indeed, unaffordable in Pakistan. The Judge had access to the financial documents from the sponsor and the sponsor’s spouse, and it was open to the Judge to find that there were sufficient finances available to pay for care required. The Judge also noted that the appellant had not discharged the burden in respect of Edhi Homes and, consequently, no arguable error arose on this basis.”
4. On 17 November 2025 the matter came before Upper Tribunal Judge Mahmood and Deputy Upper Tribunal Judge Alis. In considering article 8 ECHR, they found the FtT focused heavily on the physical separation of 25–28 years and concluded it was a “family choice” to live apart and that consequently there was nothing “over and above the usual love and affection”. The Tribunal found that the FtT’s finding that there was no family life was flawed because it had failed to demonstrate it had considered all available evidence, in particular medical evidence and evidence of regular visits, before reaching that decision and consequently had failed to carry out a balancing act assessment.
5. Having found an error of law the Tribunal adjourned the appeal for a substantive hearing and gave directions for the service of additional evidence by the Appellant by 8 December 2025 and a response to such evidence by 15 December 2025.
6. On 23 February 2026, outside of the period for service, the Appellant’s representatives served a new composite bundle of 514 pages which included 86 pages of new evidence (pdf pages 33 to 119). This bundle included statements from Romana Kanwal (pages 34-36), Asma Yasim (pages 37-39), Akil Abbas (pages 40-41), Hamayon Shahzad (pages 42-44), Sehrish Naz (pages 45-47) and Umar Abbas (pages 48-49) as well as pictures of the Appellant and her current circumstances including details of her medical records (pages 75-81). On 9 March 2026 a further bundle of 32 pages was served containing evidence from Holistic Healthcare Services, a witness statement from Huzaima Atif and evidence of money transfers.
7. The substance of the Appellant’s claim was that she was incapable of looking after herself and there was no one in Pakistan who could care for her. It was further argued that the Appellant, the Sponsor and other UK family members who had all attended the hearing and provided witness statements, enjoyed family life and that the Appellant was dependant on the Sponsor and other family members over and above the usual emotional and financial support.
8. At the outset of the hearing we agreed, with the consent of Mr Grigg, that we would take oral evidence from the Appellant’s daughter, Romana, and possibly one other witness if Mr Grigg believed it would take matters further.
9. During the hearing Mr Grigg asked for permission to potentially serve additional evidence from Holistic Care Services which was only now being requested. We refused that application for three reasons:
(a) Direction for service of evidence had been given following the error of law hearing on 17 November 2025 and that allowed the Appellant to serve further evidence by 8 December 2025. Evidence had been served on two occasions and on both occasions, this was served outside the date for service. Whilst the Respondent had not objected to other late evidence including evidence served on 2 March 2026, we were satisfied it would not be appropriate to admit evidence that may or may not be obtained as that could require a response by the respondent and further delay which was not in the interests of anyone.
(b) Mr McVeety would, in any event, be relying on the July 2024 CPIN- Pakistan: Healthcare and medical treatment as well as Holistic Care Services own website which contradicted what was stated in their emails.
(c) Allowing further evidence would not, in our view, take the parties’ respective positions any further as at best Mr Grigg would be relying on what the email/letter might say and Mr McVeety would continue to rely on the CPIN and what their own website stated.
THE EVIDENCE
10. Ms Kanwal adopted her statements (pdf pages 34-36 & 125 to 129) and gave oral evidence. She stated that her mother continued to live in the family home, but her health was deteriorating. Her mother suffered with memory loss as well as the other conditions described by the doctors. When asked how long she had suffered with dementia, as referred to in a letter from Holistic Healthcare Services produced in the Appellants supplementary bundle, she stated that her mother was still undertaking tests. None of the family had been to see the Appellant since her last visit between 11 & 30 December 2025. During that visit she noticed her mother was unable to cook a proper meal for herself and relied on snacks such as porridge and bread or meals prepared by neighbours who would check in on her every couple of days. When it was suggested to her by Mr McVeety that the photographs (pages 50-54, 61 & 63-65) did not show that she was undernourished she stated that her mother was unable to stand or cook because of her arthritis.
11. With regard to apparent discrepancies in the prognosis contained in the radiology reports (pages 482- 483) and Dr Sandhu’s report (page 468), as pointed out by Mr McVeety, the sponsor stated that the radiology reports were 12 months old and her mother had worsened since that time. When asked about her mother’s epilepsy she stated that she had two episodes a week and in the last ten days she had suffered three episodes. Despite the frequency of these episodes her medication had remained the same although on her last visit she had taken her to see the doctor about a review of her medication. As for her mother being cared for in Pakistan, she maintained that she had spoken to the professionals who stated that due to her range of problems they could not provide care for her be that in a care home or at her house.
12. The supporting statements described how the Appellant’s family had come to live in this country and set out when they had each last visited the Appellant. They each spoke about the difficulties the Appellant faced and their family and private life with the Appellant. Each statement described how they did everything for the Appellant on their visits including cooking all her meals, providing her with the correct medications, helping with hygiene care, showering, ironing her clothes and cleaning her home. All emphasised long‑standing family separation, emotional distress, and repeated short‑term travel from the UK to provide personal care. They described the practical impossibility of sustaining such arrangements because of employment, childcare, and, for some, caring responsibilities for the Appellant’s husband in the UK (who has advanced dementia).
13. A consistent theme—repeated by each witness—was that no immediate family member remained in Pakistan, and that the Appellant could not safely manage daily tasks without supervision. Witnesses described episodes where the Appellant had injured herself during seizures, her reliance on neighbours for medication and food, and her increasing confusion, weakness and falls. Their accounts stressed cumulative emotional harm to the family caused by the uncertainty of remote care and the constant need to telephone neighbours to check if she is conscious or safe. Several witnesses confirmed visits to Pakistan in 2024–2025 to care for her directly, describing the emotional burden of leaving her behind each time.
14. The witnesses collectively stated that private maids were unregulated and had previously stolen from the Appellant. They claimed that emotional and physical care can only realistically be provided here. They were able to provide adequate accommodation and stated no public funds would be needed.
MEDICAL EVIDENCE
15. The Appellant is said to suffer with deteriorating physical health including epilepsy, diabetes, arthritis and mobility impairment. The recent email from Dr Saleem (Holistic Healthcare) on page four of the latest bundle also said the Appellant had “complex dementia”.
16. We had before us several reports outlining the Appellant’s medical issues:
(a) Dr Latif (based in UK) provided a report following a zoom consultation on 3 November 2023. He concluded that if the Appellant remained in Pakistan, it would have a detrimental impact on her causing her mental health to deteriorate and no doubt her physical health conditions will also deteriorate further.
(b) Letter dated 26 June 2023 from Amina Hospital stating the Appellant suffered with epilepsy and type 2 diabetes. Recent episodes of epileptic seizures have adversely affected her quality of life and affected her mood and mental health.
(c) Letters from Corkland Road Medical Practice (UK) dated 15 October 2015 confirmed she was diagnosed with epilepsy and type 2 diabetes, and she continued to suffer with numerous seizures which resulted in a change in her medication on or around 16 January 2014.
(d) UK medical records from February 2014 confirmed type 2 diabetes and epilepsy.
(e) Dr Sandhu provided a report dated 4 March 2025 in which he described the Appellant being under his care for extreme arthritis affecting her shoulders and knees coupled with type 2 diabetes, uncontrolled epilepsy and hypertension. He stated her arthritis meant she had limited mobility and severe joint pain which increased the risk of accidents making constant supervision essential for her safety. He also stated the Appellant was unable to perform basic self-care tasks independently and needed assistance. He believed she would benefit from 24-hour supervision by a trained caregiver or family member.
(f) Dr Butt, consultant neurologist in Lahore, provided a supporting letter dated 5 March 2025 detailing her ongoing uncontrolled epilepsy that posed significant risk to her safety when unaccompanied. The need for continuous round the clock supervision was needed.
(g) Dr Mirxa, the Appellant’s physician, provided a letter dated 13 March 2025 which listed the Appellant’s current ailments including epilepsy, arthritis, diabetes, hypertension, high blood sugar level, elevated cholesterol levels and above normal renal function. His/her recommendations included consistent monitoring of both cholesterol and blood sugar levels.
(h) Dr Mughal, assistant consultant radiologist, reported on the Appellant’s X-Ray results on her knee joints from 5 March 2025. They revealed “marginal osteophytic osteoarthritic changes noted in bones forming both knee joints, subchondral sclerosis & tibia spiking observed, reduction in bilateral patellofemoral & medial compartment of tibiofemoral joint spaces. There was no evidence of intra-articular loose body or focal bony sclerotic/lytic lesions and surrounding soft tissues showed unremarkable evidence of calcification.
(i) Dr Masood, associate consultant radiologist, reported on the Appellant’s X-Ray results on her shoulder from 5 March 2025. The head, neck and visualised shaft of left humerus appeared normal. The AC joint showed reduced joint space with mild subchondral sclerosis. Marginal osteophytes were noted at the superior aspect of the coracoid. Her scapula and visualised ribs were normal. No focal or sclerotic lesion was seen. Regional soft tissues without any abnormal calcifications were grossly unremarkable. Age related osteoarthritis changes were mild.
(j) When tested on 6 March 2025 her cholesterol levels were heightened (200). Her tests on 25 December revealed a lower cholesterol level of 171 and her cholesterol to HDL had improved. Her mean glucose levels had worsened.
(k) Dr Saba Saleen, a healthcare services manager, from Holistic Care Service provided emails and letters dated 2 March 2026 in which she stated she had reviewed the Appellant’s medical records, clinical history and functional status and their conclusion was she needed long term personal and clinical care. She stated that their business was unable to provide the specialised level of care needed as they did not have the appropriately qualified staff to manage her complex dementia, psychiatric comorbidities and multi chronic illness at the intensity and supervision level her condition needed. She further stated they did not have any residential or specialised care centre in Gujrat, Sarai Alamgir or Jhelum.
SUBMISSIONS
17. Mr McVeety submitted when considering the application under the Immigration rules ADR 5.1 applied and the Appellant must therefore show she needed long term personal care to carry our daily tasks. Whilst the Respondent accepted the Appellant was not in perfect health there was no evidence of dementia and contradictory evidence on the severity of her arthritis. The Appellant’s daughter claimed in her oral evidence that the Appellant had three fits in the previous ten days a week and on average two fits a week but despite this her medication had not changed since she took her to the doctors in December 2025. There was a differing in the medical opinion about her arthritis as one medic said it was mild and one says extreme. Mild arthritis did not support her claim she could not stand, move or get out of bed. Mr McVeety submitted that there was, in his opinion, some exaggeration of her condition because if she was so bad how could she do anything without the regular help she would need. The latest photographs did not support a claim she could not cook or look after herself and the fact her cholesterol readings remained high suggested she was eating albeit perhaps the wrong things. Whilst the Appellant may occasionally need help, the fact she continued to live alone meant it was not accepted she met ADR 5.1.
18. However, even if the Tribunal accepted ADR 5.1 was satisfied, the Rules (ADR 5.2) made clear that the availability of care within Pakistan had to be considered. The two recent documents from Holistic Care Services suggested they could not provide such care, but this went against what their own website advertised and what was reported in section 21 of the July 2024 CPIN. Their own website and the CPIN undermined the emails now relied on. At the previous hearing the FtT found the Sponsor and her siblings had the funds to pay for her care as they stated there would be no recourse to public funds and if that was the case here then the same would equally apply in Pakistan.
19. If the Rules were not met, then the Tribunal should consider what Court of Appeal said in IA & others v SSHD [2025] EWCA Civ 1516. The requirement to meet the Rules was an important factor. The UK family have lived apart for some time, and it was not accepted the Appellant, or her family had a right to choose where the Appellant lived. There were no compelling and compassionate circumstances beyond normal emotional ties. Mr McVeety submitted their ties were normal and were insufficient to amount to family life. Even if family life was engaged the refusal of entry clearance would still be proportionate.
20. Mr Grigg invited the Tribunal to allow the appeal. In response to Mr McVeety’s submissions he stated that comments on photographs are not appropriate. The Appellant has needs which the family currently provides both remotely and in person when they can visit. The need is to protect her and the fact they need to monitor her via video calls was important. Their concern was she could fall and such a fall could lead to her death. He submitted this was an extreme example of a cohesive family team providing support.
21. Mr Grigg argued the letters from Holistic Care Services contained an error concerning dementia. There had been and remained an offer to clarify the letter in the new bundle. The conclusion in the letter still applied and whilst there was a reference to complex dementia this was not a submission now made. The Respondent relied on the company’s website, but that content should be balanced against the letter contained in the bundle which says the care is not provided particularly in the Appellant’s location. No weight should be given to assertions contained on a website when there was a letter clearly stating these services were not available.
22. As regards differences between the x-ray reports and Dr Sandhu’s report, Mr Grigg submitted it was not the radiographer’s job to give a diagnosis as their role was to produce material to be sent to a consultant. There are comments about the shoulder and hip scans and document on page 483, but this was simply a lab report and should be read alongside the report contained on page 482 which confirmed the Appellant’s problems. The specialist report is his opinion of the scans.
23. Mr Grigg relied on the recently submitted skeleton argument, and he submitted the Appellant’s relationship with her family amounted to more than emotional ties. The test laid out in IA (paragraphs 116, 119 and 120) sets out the test to be applied and on any interpretation of her conditions the test was met. Financial dependency was demonstrated (pages 329 to 341 plus evidence in the new bundle) as was their practical and emotional support (video monitoring (page 154)). There had been no challenge to what said on page 155 about the risk of the Appellant falling and banging her head. The Appellant’s family had visited her despite having their own responsibilities. There was sporadic assistance from neighbours, but the risk remained on all the other days.
24. The Tribunal had previously found ADR 5.1 was met (para 40 of decision). Mr Grigg submitted that ADR5.2 was also satisfied because facilities or care from Edhi centres were not sufficient. There was no evidence that the necessary care was available but even it was available it had to be reasonable for this Appellant as per paragraph 59 of R (Britciss) v SSHD [2017] EWCA Civ 368. The emotional bond with her children cannot be replaced by third party support according to the expert report- see page 155-159.
25. Mr Grigg submitted that family life was established and engaged. The Appellant had has also enjoyed private life as well in this country between 2013-2015. Article 8(2) was also met as there was a strong emotional dependency, the Appellant needed to rely on daily assistance, there was a fear of receiving professional care and the family could support and accommodate the Appellant without recourse to public funds. The proportionality assessment was in favour of allowing the appeal.
DISCUSSION AND FINDINGS
26. This was an application by a 68-year-old woman to enter this country as an adult dependant. The relevant Immigration Rule to be applied was Appendix ADR and in particular the Tribunal must have regard to ADR 5.1 and 5.2 as these would determine whether this Appellant satisfied the Immigration Rule when the application was initially considered. If the Rule was met at that date, then it would follow the appeal would succeed under article 8 ECHR. However, if the Rule was not met then the Tribunal would then have to consider the position under article 8 ECHR and in doing so the Tribunal would have to consider whether the Rule was met at the date of hearing.
27. Appendix ADR provides as follows:
“ADR 5.1. The applicant, or if the applicant is applying as a parent or grandparent, the applicant’s partner, must as a result of age, illness or disability require long term personal care to perform everyday tasks.

ADR 5.2. Where the application is for entry clearance, the applicant, or if the applicant is applying as a parent or grandparent, the applicant’s partner, must be unable to obtain the required level of care in the country where they are living, even with the financial help of the sponsor because either:

(a) the care is not available and there is no person in that country who can reasonably provide it: or
(b) the care is not affordable.”
28. The medical evidence, records and reports, identify her issues which included arthritis affecting her shoulders and knees coupled with type 2 diabetes, epilepsy and hypertension. We have reviewed this medical evidence and whilst Mr McVeety made submissions on whether Appendix ADR 5.1 was engaged, one fact remained unchanged namely the Appellant has type 2 diabetes and epilepsy.
29. Mr McVeety took issue over claims the Appellant’s epilepsy had apparently deteriorated and this is something that we will return to later in this decision, but his submission did not alter the fact the Appellant had those conditions.
30. Our starting point in this appeal was the FtT’s decision because although that decision was set aside in the appeal, the challenge to that decision related to how the FtT applied article 8 ECHR to its findings rather than the specific findings themselves.
31. At paragraph [40] of that decision the FtT found:
“I find that the Respondent is correct that the expert psychologist is not the correct expert to opine on the physical medical conditions, but taking into account the witness statements of the Appellant, the Sponsor and the Sponsor’s husband, and the UK and Pakistani medical records, I find that the Appellant as a result of her illness in respect of her physical conditions of epilepsy and type 2 diabetes requires long-term personal care to perform everyday tasks.”
32. We saw no reason to depart from the finding the Appellant required long-term personal care to perform everyday tasks.
33. However, to succeed under the Rules the Appellant also had to also satisfy Appendix ADR 5.2. We must consider whether “the care is not available (in Pakistan) and there is no person in that country who can reasonably provide it, or the care is not affordable.”
34. The evidence submitted to us and the Respondent was that the Appellant’s UK family were financially responsible for the Appellant and were she granted entry clearance there would be no recourse to public funds. At no time have the UK based family submitted they could not afford the care required in Pakistan. Their argument has always been that the care required was not available. We have therefore assessed all the available evidence on this issue.
35. The evidence relied on by Mr Grigg was the evidence of Dr Sandhu, Holistic Care Services and the oral and written evidence of family members. Conversely, Mr McVeety argued there was suitable care and he relied on firstly Holistic Care Services own website (https://holistic.com.pk/) and the 2024 CPIN.
36. Ms Kanwal gave oral evidence to the Tribunal and stated that on her last visit to Pakistan she took the Appellant to the Edhi Welfare Centre, Gujrat. She spoke to Ikram Bitt who was the chairman of that particular centre who told her “… that Edhi Centres are not care homes but are shelters for abandoned people. Mr Butt stated they do not take in people or take care of people as a care home would. He informed me that they do not have any facilities, doctors or accommodation for those who have medical conditions. Mr Butt informed me that they do not take anyone in who has family or is not abandoned.” Ms Kanwal added that she felt unsafe in the centre due to a lack of employees and because there were no women in sight.
37. There was also in the original bundle (pdf pages 169 – 189) a report prepared by Mr Asad Khan dated 23 September 2024. Mr Khan has no personal experience of care homes or care services as according to the report he is a barrister at law. He prepared his report based on instructions from the Appellant’s solicitors. He was asked to provide an opinion on (a) the current state of elderly care in Pakistan without any support from immediate family and (b) was there any suitable support available in Pakistan which can substitute the care that she is likely to receive from her sponsors in the UK? How would such care, if available, compare to the care she would receive from her UK sponsor by staying in a family setting with her children.
38. Mr Khan reported that an elderly woman living alone in Pakistan—particularly one with the Appellant’s multiple health conditions would face significant and compounding difficulties. He said that her situation was worsened by the absence of close family support in Pakistan. He also referred to there being a heightened vulnerability to neglect, exploitation and social isolation for elderly women without family protection. He stated that Pakistan does not have a regulated or reliable system of long‑term elder care. Care within the home was traditionally provided by family members; formal care services were extremely limited and geared toward short‑term or task‑specific assistance rather than continuous personal care. Domestic workers (“maids”) were untrained, unsupervised, and there was documented risk of abuse, exploitation and theft, particularly where the service-user was elderly, female, and alone. Mr Khan stated that the types of physical and emotional care the Appellant required—daily supervision, medication management, safeguarding, and gender‑appropriate intimate care—could not realistically or safely be provided through the informal care market. Care homes in Pakistan were few, unregulated, generally poor in quality, and culturally stigmatised associated with abandonment and used largely for destitute or abandoned persons rather than medically vulnerable elders. He highlighted that such institutions lacked the staffing, medical facilities, oversight structures, or safeguarding mechanisms needed for someone with the Appellant’s conditions. The report concluded that institutional placement would expose her to serious practical and cultural disadvantages and may increase—not reduce—risk of harm. While private healthcare existed, Mr Khan explained that it was costly, inconsistent in standard, and inaccessible as a substitute for continuous personal care. Hospital‑based treatment did not replace daily supervision and support. He stated that Pakistan’s broader economic instability, limited mental‑health provision, and weak systems of regulation in the care sector made it unrealistic that the Appellant could secure safe, adequate, and continuous long‑term care, even with financial assistance from abroad. His overarching conclusion was that the level of care she requires is not realistically obtainable in Pakistan, and that long‑term, gender‑appropriate personal care could only be reliably and safely provided by her children in the UK.
39. The 2024 CPIN contains a section on the Edhi Foundation which stated:
“The Edhi Foundation, run by the help of volunteers, … has set up 18 homes all over Pakistan (seven homes are running at Karachi). As a whole, 8500 younger boys and girls including elder ladies and gents have been accommodated in 18 homes. Among them, are abandoned and orphan boys and girls, mentally retarded and physical disabled, as well as for the shelter-less and helpless male and female people are living in these exclusive Edhi homes. Besides, the tortured women in the aftermath of domestic violence also reside there. The number of Edhi homes which have been established at different cities of Pakistan are stated here as—Karachi 7, Multan 1, Lahore 3, Islamabad 1, Peshawar 1, Quetta 1, and Chitral 1. The residents in the Edhi homes are numbered at 8500.
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).”
40. The Edhi Foundation website (link in the CPIN) states it is “a top charitable organisation in Pakistan and a global leader in social welfare. Operating on a non-commercial, non-political, and non-communal basis, it provides round-the-clock service without discrimination based on colour, class, or creed. Mr. Abdul Sattar Edhi and Mrs. Bilquis Edhi have received numerous awards and shields from governmental and non-governmental organisations at national and international levels for their outstanding humanitarian services across various fields.” It claimed to provide “compassionate and accessible healthcare to all.”
41. Paragraph 21.1.3 of the 2024 CPIN referred to Holistic Healthcare Services which was a company the Appellant’s representatives had contacted as evidenced by the latest evidence in the Appellant’s bundle. The CPIN stated the company was located in Lahore, Islamabad, Faisalabad and Karachi and they provided care for relatives at home in Pakistan including physiotherapy, speech and occupational therapy, assistant nurses, caregivers, ICU trained nurses, medical attendants, psychotherapists, general physicians and disabled care. The CPIN also contained a link to Holistic Healthcare Services’ website and according to https://holistic.com.pk/services/caregiver-services/ the company was able to provide onsite carers, 24/7, who were capable of doing all of the following tasks:
a. Medication Reminders
b. Room Organisation
c. Body Massage
d. Companionship & Socialization
e. Positioning and Mobility Assistance.
f. Meal Preparation and Eating Assistance
g. Toileting and Bathing Assistance
h. Body hygiene Maintenance
i. Dressing and Grooming
j. Diaper Changing
42. The website (https://holistic.com.pk/services/medical-attendants/) also stated that they offered handpicked, trained, and certified caregivers and medical care professionals in Pakistan. These professionals offered assistance with a patient’s mobility, feeding, maintaining hygiene, and medical first aid in case of emergencies. The professional bedside nursing care at home will help you with:
a. Bed bath, sponge bath, or oral hygiene maintenance
b. Feeding and bathroom assistance
c. Assistance in exercise and walking
d. Turing position for bedridden elderly
e. A friendly and reliable companionship with polite conversation
f. Monitoring sugar, BP, and temperature
g. Check on doctor’s appointments.
h. General and grocery shopping trips
43. The website also advertised that they offered more medically qualified staff and services and under the heading “Who we are” it says “With our years of vast hands-on experience in Home Nursing Services, today our Company is Top-1 with the largest team of 525+ staff members, more than 11,000 patients treated, operations in 50 cities, and main offices in Lahore, Islamabad, Faisalabad, and Karachi”
44. Mr McVeety drew our attention to this website and the content of the CPIN and submitted that this evidence contradicted what the letter and email from the same company suggested. Those letters were signed by Dr Saba Saleem who according to the letter was a Healthcare Services Manager. The website identified her as a nursing services manager and a doctor of physiotherapy who had been working with the company since 2020.
45. Her letter/email suggested that “Holistic Healthcare Services is currently unable to provide the specialized level of care required for Mrs. Zahida Nasreen condition. We do not have appropriately qualified trained staff with advanced expertise in managing complex dementia, psychiatric comorbidities, and multi-system chronic illness at the intensity and supervision level her condition needs.”
46. Mr McVeety pointed out, and Mr Grigg acknowledged, that despite oral evidence from her daughter that the Appellant’s memory was getting worse, there was no medical evidence that the Appellant suffered with any form of dementia. Her letter/email also appeared to contradict the company’s own website and what the CPIN reported. The letter from Holistic, which the Appellant relies upon, says we don’t operate care homes in Gujrat, but we found that letter was not wholly reliable given the reference to dementia which has since been retracted. At CPIN 1.1 there is reference to healthcare in general and in section 9, geriatric healthcare, there is reference to care homes. So, there is evidence of other care available.
47. Mr Grigg did seek to apply for time to obtain a letter of clarification but for the reasons given above we were not prepared to allow the submission of any further evidence in this appeal. Mr Grigg suggested we should not accept everything written on the website, but we had no reason not to. Mr Khan, who had written a report in support of the claim, had not suggested the company falsely advertised or that their advertised services were not available. The website advertised the availability of live-in nurses/assistants/carers which is exactly what this Appellant claimed she needed albeit we noted she did not currently have that level of support and relied on neighbours calling in every other day and leaving her food in the kitchen which presumably she would heat up and eat herself as there was no suggestion in her daughter’s evidence that they came and fed her or provided any other service twice a day (morning and evening). Mr Grigg submitted that services were not offered where the Appellant lived but their own website suggests “their services could be accessed in cities like Karachi, Lahore, Faisalabad, Islamabad and many more” - (see for example; https://holistic.com.pk/services/caregiver-services/ and https://holistic.com.pk/services/medical-attendants/)
48. Mr Khan’s report referred to the issue of cost but for the reason given above we were satisfied finance was not an issue for this family as collectively they provided financial support to the Appellant.
49. Whilst it may well be that Ms Kanwal’s view of the Edhi centre was partially in line with the 2024 CPIN, her evidence that care was not available appeared at odds with both the 2024 CPIN and Holistic Health Services who provide care within the person’s home. There was nothing on their website that suggested that providing care for the Appellant in her home in Gujrat would not be possible even though their key locations were Lahore, Islamabad, Faisalabad and Karachi.
50. Having considered the totality of the evidence we were satisfied the Appellant could obtain care assistance in Pakistan and there was no evidence that such care was not affordable.
51. We therefore concluded that Appendix ADR of the Immigration Rules was not met.
ARTICLE 8
52. Mr McVeety submitted the Appellant had failed to demonstrate there was either family or private life for the purposes of article 8 ECHR.
53. We were dealing with an adult dependant as against a minor child. The law in such a situation has developed since the court considered the same in Kugathas. The Court of Appeal in the recent decision of IA confirmed that the correct test for establishing Article 8(1) family life between adult siblings was the longstanding Strasbourg standard requiring “additional elements of dependence, involving more than the normal emotional ties”. This test, drawn from Kumari and endorsed domestically in Beoku‑Betts, applied equally to relationships between adult siblings as it does to those between parents and adult children.
54. The court made clear the inquiry was inherently fact‑sensitive and required a holistic assessment of whether the relationship displayed a degree of dependency — whether physical, financial, emotional or psychological — that goes significantly beyond ordinary familial affection. It was not necessary to show exclusive or complete dependency, but something materially greater than the baseline emotional connection typical of adult family relationships must be demonstrated.
55. The Court further held that the domestic notion of “real, committed or effective support” drawn from Kugathas was for the Strasbourg dependency test. Support may be relevant evidence, but it was not determinative. Support could exist without establishing dependency, and even effective support may fall short of demonstrating the substantial, meaningful reliance required.
56. The Tribunal’s task was to decide whether, taken as a whole, the relationship exhibited actual dependence of a nature and intensity capable of elevating it into Article 8(1) family life. The Court emphasised that rigid sub‑tests should be avoided and that the focus must remain on whether, in substance, the adult siblings’ relationship reflected dependency going beyond normal emotional ties.
57. The Appellant has lived alone in Pakistan since 2000 which was when her daughters, Romana and Sehrish Naz, came to live in this country. Romana’s father came to this country in 1977 and in 1997 Romana’s siblings, Asma and Hamayon, came to live in this country. Romana and Sehrish split their time between Pakistan and the United Kingdom until Romana married in 2008. All the Appellant’s children have their own families now. There was evidence the Appellant had visited this country and had applied to remain and when her application was refused, she left. Subsequent applications to visit appear to have been refused.
58. Based on the evidence before us we accept the Appellant continues to live in the family home and is financially supported by her children in this country. There was no evidence of any independent income and there was some evidence that her children had visited her in 2024 and 2025.
59. On the issue of whether there is family life we have had to decide whether their support be that physical, financial, emotional or psychological went significantly beyond ordinary familial affection.
60. Reliance was placed on the report of Dr Latif who stated the appellant’s children have a strong emotional dependency on her children and their families. We have taken this into account. We accept there is financial support and we also accept that by visiting and calling (audio/video) there was emotional support.
61. Looking at the level of visits, it is difficult to say the family were providing daily or regular physical support as their times here were limited. Their relationship is one of parent and adult children and we are satisfied that in today’s world it is not uncommon for parties to speak regularly by phone or to use video calling to keep in touch. Such behaviour does not, in our view, go beyond ordinary familial affection. The fact there is financial support again is perhaps not unusual given the Appellant has no personal income and relies, as is customary, on her children for support. Again, such support does not, in our view, go beyond ordinary familial affection.
62. The Court of Appeal made it clear that when deciding whether there was family life it would be a fact sensitive assessment and having considered all the evidence we are not satisfied there is family life. However, we have proceeded on the basis that even if there was family life refusal of entry clearance would be proportionate.
63. The public interest lies in the maintenance of effective immigration controls. To strike a fair balance between the competing public and individual interests involved, we adopt a balance-sheet approach:
a. The Appellant did not meet the requirement of Appendix ADR of the Immigration Rules either at the date of application, decision or this hearing.
b. There is nothing to add to the public interest in the maintenance of effective immigration controls.
c. Given her age English language would not be a requirement under the Rules.
d. The Appellant could be cared for by her family although it was clear she would require ongoing medical care. The sponsors offered to give an undertaking in this regard.
e. The Appellant has lived in in Pakistan all her life, save when she has been allowed to come to this country. There appears to have been a two-year period in 2013 when she came for a visit and then tried to extend her stay. After her claim was refused it appears she returned to Pakistan and all subsequent applications have been refused.
f. The Appellant has been financially supported in Pakistan by her family, and we are satisfied this would continue regardless of where she lived.
g. She has lived alone for over ten years and longer if you calculate that time from when Ms Kanwal and her sibling left Pakistan in 2000.
h. Despite her ailments she manages to
i. take her medication.
ii. get herself in an out of bed on a daily basis.
iii. use the toilet.
iv. feed herself.
v. live alone in the family home.
i. She receives support from her neighbours who call in to see her and help with meals every other day. There was no evidence on her medical records that she was not eating regularly and if anything, her cholesterol and sugar levels were higher than they should be.
j. Although she claimed her epileptic fits had worsened there was no evidence of this or that her doctors felt her medication should be increased despite a visit to the doctors in December 2025. There was evidence her medication had been increased, when needed, in the past.
k. She suffered with arthritis and diabetes but the x-ray reports, provided by the Appellant, did not suggest her arthritis was as debilitating as she claimed.
l. There was evidence that home care could be provided by a private company at a cost. There was no evidence to suggest the family could or would not pay this.
m. It was argued she had established a private life in this country between 2013 and 2015, but little weight should be attached to this period as her immigration was precarious throughout that period.
64. The Appellant must demonstrate exceptional circumstances which would result in unjustifiably harsh consequences. It was not sufficient to show her circumstances were simply unusual or difficult. It is necessary to prove the consequences of a refusal would be disproportionate and not justified by the public interest, such as that in maintaining effective immigration control.66. Drawing together all the evidence and the applicable legal framework, we were satisfied that the refusal of entry clearance would not produce consequences that were unjustifiably harsh when assessed under Article 8 ECHR.
DECISIONS
65. The decision of the First-tier Tribunal has been set aside. We have remade the decision in respect of Article 8 ECHR by finding that refusal of entry clearance would not produce consequences that are unjustifiably harsh when assessed under Article 8 ECHR. The appeal is therefore dismissed.
66. There is no order for anonymity as we saw no reason to make one on the facts of this case.

Deputy Upper Tribunal Judge Alis
Immigration and Asylum Chamber
18 March 2026