Rebecca Beaumont, Director of Investigation Services at TMLEP, considers the impact of poor documentation in the context of the recent case of Shaheen and Ahmed (As Executors of the Estate of Mr Ajaz Ahmed) v Dr Joanna Daish [2025] EWHC 3056 (KB).
Medical records are the key reminder of clinical interactions with patients. Professional standards are set for record keeping by all regulatory bodies, emphasising their importance in clinical practice. An example is the standard set in the General Medical Council’s Good medical practice guidance from 2024, which states at paragraph 69: “You must make sure that formal records of your work (including patients’ records) are clear, accurate, contemporaneous and legible.”
The guidance goes on at paragraph 70 to indicate what patient records should include. Relevant clinical findings and treatments provided feature as one would expect, but the guidance also indicates that patient concerns and preferences relevant to their ongoing care should usually be documented, as well as any decisions made and when those decisions are to be reviewed. This illustrates that medical records are not only a contemporaneous documentation of the clinical interaction had with a patient, but also a key piece of the puzzle in ensuring continuity of care for them moving forward.
Medical records are also key evidence in investigations into healthcare and clinical negligence claims. Whilst lack of documentation does not necessarily mean that the care delivered to a patient was substandard, it does introduce risk to practitioners if they are subject to investigatory, regulatory, or clinical negligence proceedings. Investigators, solicitors, and Courts all place weight on the medical records when making findings, and silence in the medical records regarding aspects of care delivered can result in an adverse finding against a practitioner.
The recent trial of preliminary issues by the High Court in the case of Shaheen and Ahmed (As Executors of the Estate of Mr Ajaz Ahmed) v Dr Joanna Daish [2025] EWHC 3056 (KB) highlights the risk that can arise for practitioners where medical records are silent.
The claim in Shaheen and Ahmed was brought by the wife and son of Mr Ahmed, who died of lung cancer at the early age of 49. The claimants allege that there was an opportunity to intervene and treat the cancer earlier and this was missed due to the negligence of Mr Ahmed’s general practitioner, Dr Daish.
Mr Ahmed had seen Dr Daish on 11 February 2019, and she requested a chest x-ray using the Integrated Clinical Environment (ICE) system. A request made through the ICE system is not followed up or acted upon unless the patient attends a walk-in radiology department. Crucially, the record for the appointment in Mr Ahmed’s GP record noted that an x-ray had been requested but was silent on the exchange between Mr Ahmed and Dr Daish at the appointment. The Court was therefore asked to decide whether Dr Daish communicated the need for a chest x-ray to Mr Ahmed and advised him that he needed to attend a walk-in radiology department for this to be undertaken.
As no note was made in the GP record of the discussion and Dr Daish had, understandably, no recollection of the appointment, she relied on her usual practice. Dr Daish asserted that she would have told Mr Ahmed about the x-ray and its purpose, namely, to rule out serious pathology including cancer. The time pressure of busy general practice was noted but Dr Daish advised that 10 minutes would have been sufficient time for the examination and to explain the need for the x-ray to Mr Ahmed.
In weighing the evidence, the Court found in favour of the claimants and that, on the balance of probabilities, Mr Ahmed was not told about the x-ray. Several factors were determined as carrying greater evidential weight than Dr Daish’s statement including that there was no record in the appointment of any discussion about the chest x-ray. The judge particularly highlighted an “obvious contrast” (paragraph 36 (v)) between Dr Daish’s record on 11 February 2019 and the notes of other doctors in Mr Ahmed’s GP records, who had specifically noted the need for further investigations.
The case of Shaheen and Ahmed highlights the vital nature of medical records for patient safety and risk management by practitioners. Whilst silence in contemporaneous documentation will not always lead to an adverse finding against a practitioner, it can do so, particularly where there is contrasting evidence in other entries in medical records that show that such documentation is usually made.
At TMLEP, lack of documentation is a frequent feature of matters where we are instructed to provide independent expert evidence and investigation services. Our reports quickly assess such situations and provide unbiased recommendations for learning and improvement. The case of Shaheed and Ahmed shows that silence in documentation is a risk that healthcare providers should not overlook. Engaging with recommendations made in TMLEP’s reporting can aid in systemic improvements which will mitigate such risk.
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