Dr Samah Boulis is a very experienced General Practitioner who provides expert evidence in medico-legal proceedings. She works as a full time NHS GP and is fully registered with the General Medical Council and is also on the Medical Performers list for GPs

Summary

Modern digital systems generate a detailed electronic footprint, including timestamps, document revisions, communications, task completion, and other system-generated metadata. These audit trails can provide an objective chronology of events that extends beyond the primary documentary record.

In Shaheen and Ahmed v Daish, the electronic audit trail demonstrated that elements of the management plan, including the chest X-ray request, were completed after the consultation had ended. While entirely consistent with routine clinical workflow, this chronology became legally significant because it supported the inference that there was no contemporaneous evidence that the patient had been informed about the investigation or how to access it.

The wider lesson for expert witnesses is that electronic audit trails should be analysed alongside the primary records. Whether reviewing healthcare records, engineering documents, financial systems or other digital records, audit data can corroborate or challenge witness recollection, reconstruct the sequence of events, and identify discrepancies between what was done, what was recorded, and what was communicated.

Learning Points for Expert Witnesses

• Identify the real issue in dispute. The central question is not always whether the professional decision or technical process was appropriate, but whether the key facts can be established from the available evidence.

• Prioritise contemporaneous evidence. Courts generally place greater weight on contemporaneous records, electronic audit trails, timestamps and other objective evidence than on retrospective recollections or evidence of "usual practice".

• Analyse the digital audit trail. Electronic systems often provide an objective chronology of events. Audit logs, timestamps and system metadata should be considered alongside the primary records when reconstructing what occurred.

• Distinguish actions from communication. Completing a task or initiating a process does not necessarily establish that relevant information, instructions or advice were communicated to the intended recipient.

• Recognise that silence may be significant. Where records contain no evidence that an important discussion or instruction took place, the court may conclude that it probably did not occur, particularly where similar matters are routinely documented.

• Understand the limits of "usual practice". Evidence based on habitual practice is generally less persuasive than objective contemporaneous documentation and should be interpreted accordingly.

• Assess whether communication enabled appropriate action. Where responsibility passes to another individual or organisation, experts should consider whether sufficient information was provided to enable the next step to be undertaken safely and effectively.

• View documentation as objective evidence. Accurate records support continuity, accountability and provide reliable evidence of events, decisions and communications.

• Consider behaviour in context. Courts may assess how an individual would probably have acted if appropriately informed, taking into account their previous conduct and the surrounding factual circumstances.

• Apply contributory negligence cautiously. Failure to follow advice does not establish contributory negligence unless there is evidence that the patient understood what was required and the consequences of not acting.

Factual Background and Chronology 

Mr A, aged 49, consulted his GP, Dr D, on 11 February 2019 with worsening breathlessness following a respiratory infection. At consultation, he was assessed as having an asthma exacerbation, treated with inhalers and oral steroids, and a chest X-ray was requested via the ICE system. This operated as a walk-in service requiring the patient to attend radiology independently. 

The key chronology is as follows: 

• 11 February 2019: Consultation recorded examination, diagnosis, treatment, and the X-ray request. However, there was no documentation of any discussion with the patient about the investigation or how to access it. Audit data indicated that parts of the management plan, including prescribing, were completed after the patient had left, and the record was then closed. 

• 11 February 2019 (later): A text message was sent regarding medication changes only; no communication was sent about the X-ray. 

• 27 February 2019: A nurse follow-up appointment was scheduled but not attended, with no clear link to imaging. 

• 2019–2022: No chest X-ray was undertaken. There is no evidence that Mr A was aware of an outstanding investigation. 

• January 2022: Mr A stated in a witness statement that he had not been told to attend for an X-ray. 

• February 2023: Mr A died from lung cancer. 

The Claimants alleged failure to communicate the X-ray request and its process.

The Defendant relied on usual practice but had no specific recollection. The court was asked to determine breach, causation, and contributory negligence. The court was asked to determine three preliminary issues: 

1. Whether the Defendant failed to inform Mr A of the X-ray request; 

2. If so, whether Mr A would have attended had he been informed; 

3. Whether Mr A was contributorily negligent in failing to attend subsequent follow-up appointments.

The Judge’s Conclusion and Reasoning

Christopher Kennedy KC, sitting as a Deputy High Court Judge, found for the Claimants on all preliminary issues. The court held, on the balance of probabilities, that Dr D did not inform Mr A of the need to attend for a chest X-ray, despite being described as a “caring and competent” clinician.

1. Communication of the X-ray: The court relied primarily on the contemporaneous record: 

   • No documentation of discussion: The record confirmed the X-ray request but contained no evidence that it was explained to the patient, unlike other investigations in the same notes. 

   • Clinical context: Given Mr A’s anxiety about his symptoms and recent urgent attendance, the court found it unlikely he would have ignored a cancer-excluding test if informed. 

   • Audit trail evidence: The electronic audit trail showed that the ICE chest X-ray request was completed at 11:28 am, after key elements of the consultation had concluded, and that by 11:29 am Mr A had left the surgery. Although consistent with routine general practice workflow, the chronology was evidentially significant because there was no contemporaneous record that the X-ray request or walk-in process had been communicated before he left.

2. Causation: The court found Mr A would have attended the X-ray if informed, relying on:

   • prior compliance with walk-in investigations;

   • clear concern about his health; 

   • expected engagement with serious pathology exclusion. 

There was no evidence of informed non-attendance. 

1. Contributory Negligence The defence failed. The court found no evidence that Mr A knew about the X-ray or understood any risk in not attending follow-up. Nonattendance could not therefore be characterised as negligent, and the burden of proof was not met.

Conclusion 

This case illustrates that many disputes are determined not by complex technical or professional issues, but by the quality of communication, documentation and the objective evidence available to reconstruct events. For expert witnesses, careful analysis of contemporaneous records, electronic audit trails and the factual chronology is often more persuasive than retrospective accounts based on habitual practice or recollection.