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Neutral Citation Number: [2014] EWCA Civ 1522

Case No: B2/2014/2008

IN THE COURT OF APPEAL (CIVIL DIVISION)

ON APPEAL FROM THE CENTRAL LONDON CIVIL JUSTICE CENTRE

Her Honour Judge Faber

3F!"##$

Royal Courts of JusticeStrand, ondon, !C2" 2

#ate: 28 No$ember 2014

e%ore &

LORD JUSTICE LON'MORE

LORD JUSTICE LEISON

and

LORD JUSTICE URNETT

% % % % % % % % % % % % % % % % % % % % %

e*een &

'ENERAL MEDICAL COUNCIL A++e,,an

- and -

AM'AD NA.HLA Re/+onden

% % % % % % % % % % % % % % % % % % % % %

% % % % % % % % % % % % % % % % % % % % %

Mr A,an Ma0,ean 1C 2 M/ Je//0a o4d&instructed by 'MC Lega, De+ar5en' for t(e

A++e,,anMr A5gad Na67,a&not re)resented' 7e Re/+onden

*earin+ dates : 1 and 20 No$ember 2014

% % % % % % % % % % % % % % % % % % % % %

Judg5en

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Judg5en A++ro8ed b4 7e 0our %or 7andng do*n9 -.C $ Na(la

Lord Ju/0e Le*/on&

Inrodu0on

1 .r Na(la (as been )ractisin+ as a sur+eon in t(e since .ay 2003 Before 200

(e )ractised as a sur+eon in 5+y)t, 6(ic( is also 6(ere (e trained 7n No$ember 2008(e 6as acce)ted as a ello6 of t(e Royal Colle+e of Sur+eons, (a$in+ )assed t(e

RCS &9rauma and rt(o)aedics' e;amination *e (as been 6orin+ as a ocum

Consultant rt(o)aedic Sur+eon at Basildon and 9(urroc ni$ersity *os)itals since

")ril 2012 *is s)ecialty is in t(e lo6er limbs, es)ecially nees and (i)s 7n January

2012 (e a))lied to t(e -eneral .edical Council &t(e

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&b' F A and

&c' re+istered medical )ractitioners fallin+ 6it(in suc( ot(er

cate+ories as t(e @ri$y Council may by order s)ecify

&' F

&4' " )erson fallin+ 6it(in any of )ara+ra)(s &a' to &c' of

subsection &2' s(all only be included in t(e S)ecialist Re+ister

if t(ey (a$e a))lied to t(e Re+istrar for t(e )ur)ose and (a$e

)aid any fee s)ecified in re+ulations under section 4=

9(us (oldin+ a CC9 is not t(e only route to entry on t(e S)ecialist Re+ister 7n

e;ercise of t(e )o6er contained in section 4# &2' &c' t(e @ri$y Council made t(e

@ost+raduate .edical 5ducation and 9rainin+ rder of Council 2010 &

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3 " )erson 6(o satisfies t(ese reuirements is +i$en a Certificate of 5li+ibility to

S)ecialist Re+istration &a

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be remitted to t(e R"@: Hollingworth v Specialist Training Authority of the Medical

Royal Colleges200K 5!C" Ci$ 42 at 28K

A++ea,/ o 7e 0our/

11 nlie many a))eals to t(e court from s)ecialist tribunals, an a))eal to t(e countycourt from t(e R"@ is not limited to an a))eal on a )oint of la6

12 9(e county court, actin+ in its a))ellate role, 6ill normally conduct a re$ie6 of t(e

decision of t(e R"@ rat(er t(an a re(earin+: C@R @art 211 &1' 7t 6ill allo6 an

a))eal under C@R @art 11 &' 6(ere t(e decision under a))eal 6as &a' 6ron+ or

&b' un?ust because of a serious or ot(er )rocedural irre+ularity

1 9(e first +eneral )oint t(at 7 6is( to mae arises out of t(e fact t(at an a))eal to t(is

court is a second a))eal 7n a))eals of t(at ind t(e real uestion for t(is court is

6(et(er t(e intermediate a))eal court &(ere t(e county court' 6as entitled to interfere

6it( t(e decision of t(e first tier tribunal &(ere t(e R"@' 7n ot(er 6ords t(e focus oft(is a))eal is 6(et(er t(e R"@ 6ere 6ron+:Procter & Gamle !" v HMRC200K

5!C" Ci$ 40GA 200K S9C 10

14 9(e second +eneral )oint is about a))eals on fact "n a))eal from t(e R"@ is not

limited to an a))eal on a uestion of la6, but t(at does not dilute t(e reluctance 6(ic(

an a))eal court s(ould (a$e about o$erturnin+ factual conclusions actual

conclusions for t(is )ur)ose include not only findin+s of )rimary fact but also

e$aluations of t(ose facts, $alue ?ud+ments based on t(em, and t(e a))lication of t(e

facts to le+al standards 9(e a))eal court s(ould not retry t(e case on t(e transcri)t

"ll t(is is contained in t(e recent ?ud+ment of t(e Su)reme Court in McGraddie v

McGraddie201K SC 8A 201K 1 !R 24GG as 6ell as in Procter & Gamle!" at K &Jacob J', 30K &9oulson J' and Assicura#ioni Generali SpA v Ara

$nsurance Group2002K 5!C" Ci$ 1342, 200K 1 !R GG at 13K &Clare J'

.oreo$er 6(ere, as (ere, t(e a))eal is an a))eal from a s)ecialist tribunal an a))eal

courtHs reluctance to inter$ene on uestions of e;)ertise s(ould be all t(e +reater:

Procter & Gamle !"at 11K &Jacob J', 48K &9oulson J' 9(is tribunal included a

medically ualified member, and recei$ed ad$ice from a s)ecialist ad$iser

T7e :ue/on o be deer5ned

1 9(e first route to entry on t(e S)ecialist Re+ister is by (oldin+ a CC9 ne 6ould

naturally e;)ect t(at alternati$e routes 6ould be broadly eui$alent 9(at t(is is so is,in my ?ud+ment, borne out by article 8 &2' of t(e 2010 rder, because t(e )ur)ose for

6(ic( t(e Re+istrar must consider a )ractitionerHs s)ecialist trainin+ and/or

ualifications is to decide 6(et(er t(ey are sur+eon t(e reuirements are set out in t(e curriculum

for S)ecialist 9rainin+ in 9rauma and rt(o)aedics 2010, )ublis(ed by t(e Royal

Colle+e of Sur+eons 7t is t(e syllabus leadin+ to6ards t(e a6ard of a CC9, 6(ic(

ty)ically taes ei+(t years 7t is a len+t(y and detailed tec(nical document, 6(ic( it is

im)ractical to summarise 7t must also be borne in mind t(at it is a )racticaldocument, 6ritten by medical )ractitionersA and one cannot e;)ect it to e;(ibit t(e

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same $erbal )recision as a 6ell%dra6n contract, let alone an "ct of @arliament

*o6e$er, 7 must set out some e;tracts 6(ic( are rele$ant to t(e a))eal

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as t(e )rimary consultant for t(e small number of ort(o)aedic

emer+encies 6(ic( may occur F 9(e (older of a CC9K 6ould

be e;)ected to assess emer+encies as t(ey arise, resuscitate and

definiti$ely treat t(e ma?ority, referrin+ on some of t(e more

s)ecialised cases as described abo$e= &Section 3%'

1G Section 8 contains t(e detail of t(e syllabus 7t be+ins by sayin+ t(at t(ere are t(ree

com)onents: a))lied clinical no6led+e, a))lied clinical sills and )rofessional and

mana+ement 9(ese com)onents all

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lar+e number of sur+ical )rocedures, 6(ic( are far more e;tensi$e t(an t(e 14 ey

indicati$e )rocedures 7n years G and 8 almost all reuire eit(er le$el 4 or le$el 4s

21 "s to clinical no6led+e, section 10% of t(e curriculum states t(at RCS

e;amination= inally:

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+reater or more strin+ent reuirements t(an t(ose im)osed by t(e rder 7t is t(erefore

unnecessary to d6ell on it furt(er

Mr Na67,a;/ 0a/e

2 .r Na(la a))lied for s)ecialist re+istration under t(e eui$alence route in January2012 *e submitted e$idence relatin+ to (is medical )ractice in 5+y)t )rior to 200,

and in t(e since (e be+an 6or t(ere in .ay 2003 n 1G Se)tember 2012 (e 6as

told t(at (is a))lication (ad been unsuccessful *e 6as sent a co)y of t(e e$aluation

"lt(ou+( t(e e$aluators 6ere satisfied t(at .r Na(la (ad demonstrated t(e rele$ant

de+ree of no6led+e, t(ey 6ere not satisfied t(at (e (ad demonstrated t(e rele$ant

de)t( and breadt( of sills and e;)erience 9(e essential )oint 6as t(at .r Na(la

(ad substantial e;)erience of lo6er limb reconstructionA but:

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)a+es to demonstrate (is e;)erience in S)inal Sur+ery,

@aediatric rt(o)aedic sur+ery and *and *e undertoo t(is

6or bet6een 2002 and 200 !(ile t(is may be e$idence to

s(o6 t(at (e +ained com)etencies, it is too lon+ a+o to s(o6

t(at (e is maintainin+ t(em as described abo$e

*e also comments ORefer to pages '()*+ for General

Trauma and Hand e,perience in Charing Cross HospitalH 9(is

e;)erience 6as bet6een 20//2003 P 2/G/200 9(ere is not

enou+( recent e$idence in t(ese alone to s(o6 t(at (e is

maintainin+ com)etencies across t(e board

F

9(e lo+boo data )resented for t(e )eriod 1st .ay 2012 to 1st

#ecember 2012 are mostly (i) and nee o)erations 6it( a

small number of trauma cases "s suc( a+ain do not s(o6 t(enecessary breadt( reuired to meet t(e standards of t(e 2010

CC9 curriculum in 9rauma > rt(o)aedic sur+ery=

28 9(ey t(en commented on a number of

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curriculum 7n any e$ent t(at e;)erience 6as at its latest in 200 9(ey concluded at

)ara+ra)( &;':

T7e

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satisfied t(e Re+istrar t(at eit(er t(e ualifications or t(e

trainin+ or bot( 6(en considered to+et(er are eui$alent to a

CC9 in t(e s)ecialty

181 "rticle 8&' reuires t(e Re+istrar to tae into account

s)ecialist medical e;)erience or no6led+e 6(ere$er obtained

6(en determinin+ t(e adeuacy of t(e trainin+ or of t(e

ualifications

182 9(e italics are mine in an effort to distin+uis( t(e t(ree

different 6ays in 6(ic( an a))licant can )ro$e eui$alence

9(ey are by (er ualifications or by (er trainin+ or by a

combination of t(e t6o S(e does not (a$e to demonstrate

eui$alence by reference to trainin+ if s(e relies on

ualifications or by reference to ualifications if s(e relies ontrainin+

18 9(e effect of &' is t(at all acuired medical e;)erience or

no6led+e is to be taen into account 7t is not limited by

+eo+ra)(y or a+e 7t is to be taen into account 6(et(er t(e

@anel is considerin+ t(e eui$alence of ualifications or t(e

eui$alence of trainin+ or t(e eui$alence of t(e combination

of t(e t6o

184 7f and in so far as any -.C +uidance or reuirements

de)art from t(e statutory )ro$isions of t(e 2010 curriculum fort(e CC9 t(en t(ey cannot bind t(e R"@K or t(e courtF 7f t(e

R"@K treated a different )ro$ision in t(e C5SR as bindin+ and

so de)arted from t(e actual reuirements of t(e CC9

curriculum in considerin+ t(e issue of eui$alence t(en t(ey

6ould (a$e committed an error of la6=

4 Based on (er inter)retation of article 8 &2' and t(e CC9 t(e ?ud+e concluded at 228K:

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t(ree 6ays of establis(in+ eui$alence=, 6it(out re+ard to any additional trainin+ "t

1GK s(e a))eared to consider t(at trainin+ u) to t(e time 6(en .r Na(la +ained (is

status as RCS &9 > ' 6ould be rele$ant but not any trainin+ t(ereafter

3 ne furt(er )oint of inter)retation cro))ed u) later in t(e ?ud+eHs ?ud+ment 9(e

uestion 6as 6(et(er t(e reuirement in article 8 &2' t(at trainin+ and/orualifications

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set out in t(e 2010 curriculum 9(ere is no le+al reuirement in

t(e curriculum or in t(e statute for maintenance of sills to be

e$idenced "s it can tae anyt(in+ u) to 11 years to com)lete

t(e CC9 e$idence of com)etence of t(at a+e is not too old to be

taen into account 9(ere is no le+al reuirement for a @B" or

its eui$alent in )aediatric ort(o)aedics 9(e 2012 curriculumis irrele$ant to t(is a))lication 9(e in$ol$ement of @rofessor

rostic in t(e t6o e$aluations is not unfair nor is t(ere

e$idence of bias in t(e una$ailability of statistics as to

a))lications (e (as allo6ed nor in t(e statistics of a))eals

allo6ed=

40 By )ara+ra)(s 1 and 2 of (er order s(e remitted .r Na(laHs a))lication to a different

R"@ for redetermination of .r Na(laHs a))ealA and by )ara+ra)( 4 of (er order

directed t(em to a))ly t(e la6 as set out in )ara+ra)(s 180K to 18K of (er ?ud+ment

9(e +uidance t(at s(e set out at 24K &uoted abo$e' 6as set out in )ara+ra)( of

(er order, 6(ic( directed t(e R"@ to a))ly t(at +uidance

Ar0,e $ (") and 7e "!#! 0urr0u,u5

41 9(e ?ud+e 6as, in my ?ud+ment, correct to say t(at t(e ultimate ob?ecti$e of t(e

enuiry 6as to determine 6(et(er an a))licantHs ualifications or trainin+ or bot(

6ere eui$alent to a CC9 7 t(in t(at s(e 6as also ri+(t to say t(at -.C +uidance to

a))licants could not la6fully )rescribe more onerous reuirements t(an article 8 &2'

itself 9(e ?ud+e 6as also ri+(t to say t(at in considerin+ 6(et(er .r Na(laHs

ualification or trainin+ &or bot(' 6as eui$alent to a CC9 t(e Re+istrar, and (ence

t(e R"@, 6ere reuired under article 8 &' to ' ualification@rof rostic said in e$idence t(at it 6as a

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6as ' is a ' (is

s)ecialist medical e;)erience also (ad to be taen into account But t(at in itself does

not ans6er t(e uestion: is t(e RCS &9 > ' ualification, taen to+et(er 6it( .r

Na(laHs e;)erience, eui$alent to a CC9Q By (oldin+ t(at t(e RCS &9 > ' 6as

the s)ecialist ualification t(e ?ud+e )recluded any furt(er enuiry Nor do 7 acce)t

t(at in t(e case of a )erson 6(o c(ooses to rely on a ualification trainin+ is

irrele$ant 7t is clear from t(e concludin+ )art of article 8 &2' t(at t(e Re+istrar is

reuired to consider t(e eui$alence of t(e ualification, t(e trainin+ ' e;am So t(ere 6as no e$idential foundation for (er

conclusion t(at )assin+ t(e RCS &9 > ' e;am 6as a ualification eui$alent to t(e

CC9 .r Na(la relied (ea$ily on t(e descri)tion of t(e RCS &9 > ' e;am in

section 8% of t(e curriculum 6(ic( said t(at it 6ould test:

sur+eon )ractisin+ in t(e +enerality of t(e disci)line at t(e le$el

of an N*S consultant=

43 9(us, (e ar+ued, it could be seen from t(e curriculum itself t(at t(e e;am 6as not

merely a test of no6led+e 7t encom)assed sills and attitudes as 6ell .oreo$er it

tested sills, no6led+e, and attitudes across t(e +enerality of t(e disci)line, and, in

addition, did so at t(e le$el of an N*S consultant Since an a))licant for a C5SR 6as

not a))lyin+ for a CC9 6(at 6as im)ortant 6as t(e outcome, rat(er t(an t(e means

by 6(ic( t(e outcome 6as ac(ie$ed 7f t(e sills, no6led+e and attitudes of a 9 >

sur+eon 6ere tested by t(e RCS &9 > ' e;am in t(e manner and to t(e le$el

described, 6(at more 6as needed to demonstrate com)etence at t(e le$el of an N*S

consultantQ

4G 9(e ans6er to t(at $ery )ertinent uestion is, in my ?ud+ment, t(at t(e 2010 syllabus

itself e;)lains t(at )assin+ t(e RCS &9 > ' e;am is not t(e be%all and end%all

48 7 re)eat t(e essential )arts of t(e 2010 curriculum:

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t(e R"@' are entitled to )lace 6ei+(t on t(e reuirement of t(e curriculum t(at

mastery of all 14 ey )rocedures must be demonstrated

7n decidin+ t(at .r Na(la 6as not reuired to demonstrate t(at (e (ad maintained

(is com)etencies, t(e ?ud+e came to t(e o))osite conclusion to t(at reac(ed by **

Jud+e -ore C in -hannapuneni v The General Medical Council, decided in t(e.anc(ester County Court in a ?ud+ment +i$en on 14 .arc( 2014, a fe6 6ees before

t(e ?ud+eHs decision in t(is case Because 7 a+ree 6it( ** Jud+e -oreHs reasonin+ 7

6ill set it out:

additional reuirement, (ence t(e 6ord

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and it is natural to e;)ect t(at a re+istered s)ecialist (as mastered t(e latest

tec(niues "ccordin+ly in my ?ud+ment t(e ?ud+e 6as 6ron+ to re?ect t(e -.CHs

case t(at an a))licant s(ould demonstrate t(at (e (as maintained sills

8 7n fact .r Na(la did not ar+ue t(at t(e maintenance of sills 6as not reuired *e

said t(at if, for e;am)le, a candidate (ad trained as a sur+eon but (ad t(en +one on afi$e year round t(e 6orld cyclin+ tri) (e s(ould not be re+istered on t(e S)ecialist

Re+ister 6it(out demonstratin+ t(at (is sills 6ere u) to date *is ar+ument 6as t(at

t(e maintenance of sills could be +enerically ac(ie$ed, and t(at by safely and

successfully )racticin+ as a consultant s)ecialiLin+ in lo6er limb )rocedures (e (ad

demonstrated t(at (is sills 6ere bein+ maintained Com)etence meant bein+ ca)able

of 6orin+ effecti$ely 7t is im)ractical to reuire a sur+eon to co$er t(e full ran+e of

)roceduresA and )ro$ided t(at a sur+eon maintains com)etence in (is c(osen area of

interest, (e (as done enou+(

9(is 6as an attracti$e ar+ument, but 7 cannot acce)t it 9(e fundamental defect in t(e

ar+ument is t(at it do6n)lays t(e central reuirement of t(e 2010 syllabus t(at asuccessful candidate for a CC9 must demonstrate mastery of t(e 14 ey )rocedures

9(e )ur)ose of t(ose ey )rocedures, as t(e curriculum e;)lains, is to demonstrate t(e

full ran+e of sills t(at a 9 > sur+eon needs to )ossess 9(e full ran+e of sills is

necessary because t(e successful (older of a CC9, and (ence a ne6ly a))ointed N*S

consultant, must be able to deal 6it( t(e ma?ority of unselected trauma cases, rat(er

t(an sim)ly demonstrate com)etence in a sub%s)ecialty "s 7 (a$e said t(e acid test is

eui$alence So t(ere may be cases in 6(ic( t(e Re+istrar is able to tae t(e $ie6 t(at

an a))licantHs sill set is eui$alent to t(at of t(e (older of a CC9 e$en t(ou+( (e

cannot demonstrate continuin+ mastery of e$ery sin+le one of t(e 14 ey )rocedures

9(at is a uestion of ?ud+ment or, as it is sometimes )ut, of fact and de+ree 7

conclude, t(erefore, t(at t(e ?ud+e 6as 6ron+ to (old t(at:

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im)ortant 7t em)(asises t(at it is not sufficient to s(o6 6(at an

a))licant (ad ac(ie$ed but also (o6 t(ey (a$e )erformed

9estimonials and structured re)orts, 6it(out more, do not

)ro$ide )rimary e$idence and need to be trian+ulated 6it(

ot(er substanti$e e$idence suc( as 6or )lace based

assessments a ty)e of 6(ic( is F @B"s=

3 9(is statement does not reuire an a))licant to )roduce @B"s @B"s are sim)ly one

ty)e of 6or)lace assessment !(at t(e R"@ 6as looin+ for 6as e$idence of

com)etence, rat(er t(an merely a recitation of 6(at )rocedures .r Na(la (ad

undertaen 5$en in t(e (istoric conte;t of 6(at .r Na(la (ad done in 5+y)t 7 can

see no fault 6it( t(is 9(e R"@ continued in )ara+ra)( l:

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-i$en t(e coincidence of e$aluation of t(at e$idence 7 do not find it sur)risin+ t(at t(e

R"@ )referred @rof rosticHs e$idence on t(at )oint to t(at of t(e Consultant, .r

amat(

38 9urnin+ to .r Na(laHs e;)erience in t(e bet6een .ay 2003 and July 200 t(e

R"@ noted in )ara+ra)( m t(at t(ere 6as

(istoric e;)erience

G1 9(e ?ud+e said at 20GK t(at s(e 6as sur)rised t(at t(e R"@ attac(ed suc( 6ei+(t to

@rof rosticHs e$idence 6(en

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res)ects yet be accurate on one or more critical )oints 9(ird, t(e e$idence t(at @rof

rostic +a$e 6as e;)ert e$idence e$aluated by an e;)ert tribunal, 6(ic( s(ould +i$e

an a))eal court e$en more cause to refrain from interferin+ ourt(, t(e crucial )oint

on 6(ic( t(e R"@ acce)ted @rof rosticHs e$idence 6as, in effect, corroborati$e of

t(e $ie6 t(at t(ey t(emsel$es (ad inde)endently formed about t(e uality of t(e

e$idence of .r Na(laHs 5+y)t e;)erience $erall 7 am concerned t(at 6(at t(e?ud+e a))ears to (a$e done is to retry t(e case on t(e )a)ers 9(at is not 6(at an

a))eal court s(ould do

T7e 0ro//-a++ea,

G .r Na(la also a))lied for )ermission to cross%a))eal !e refused (im )ermission to

a))eal a+ainst t(e ?ud+eHs refusal to a6ard (im dama+esA but allo6ed (im to ar+ue in

fa$our of an order directin+ t(e Re+istrar to enter (im on t(e S)ecialist Re+ister rat(er

t(an remittin+ t(e matter to t(e R"@ 7 do not consider t(at t(is is a case in 6(ic( t(e

court can be confident t(at t(ere is only one realistic outcome .r Na(la says t(at (e

(as com)lied 6it( t(e informal recommendation of t(e R"@ and (e no6 (as a batc(of @B"s 6(ic( demonstrate a broader ran+e of sills t(an t(ose 6(ic( 6ere )laced

before t(e R"@ 7t 6ill be for t(e R"@ to decide 6(et(er, in t(e li+(t of our ?ud+ments

and t(e ne6 material t(at .r Na(la (as )resented, (e (as demonstrated t(e

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case no: b2/2014/2008

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