Shaheen (2025): communicating imaging requests and patient follow-up

Shaheen and Ahmed v Daish

[2025] EWHC 3056 (KB)
High Court, King’s Bench Division
Christopher Kennedy KC, sitting as a Deputy High Court Judge
Judgment delivered: 28 November 2025

Background

Mr Ajaz Ahmed attended his general practitioner, Dr Joanna Daish, on 11 February 2019 with breathlessness that had worsened over several months following a lower respiratory tract infection.

Dr Daish examined him, diagnosed an exacerbation of asthma and prescribed additional treatment. She also generated a request for a chest radiograph through the Integrated Clinical Environment system.

Under the local arrangement, the request did not create an appointment. It would be acted upon only if the patient attended a walk-in radiology department. The system generated no automatic reminder to the patient or follow-up notification to the requesting clinician.

Mr Ahmed did not attend for the radiograph.

A chest radiograph was subsequently requested by another GP in January 2020. Mr Ahmed attended on that occasion, and the investigation led to a diagnosis of lung cancer. He died on 23 February 2023 at the age of 49.

His wife and son brought proceedings as executors of his estate and on behalf of his dependants.

The preliminary issues

The court was asked to determine:

whether Dr Daish failed to inform Mr Ahmed that a chest radiograph had been requested and that he needed to attend the walk-in radiology department.
if he had not been informed, whether he would probably have attended if given the necessary information.
whether his failure to attend later clinical appointments amounted to contributory negligence.

The court was not asked at this stage to determine:

whether earlier imaging would have resulted in curative or life-prolonging treatment.
whether any delay caused or materially affected Mr Ahmed’s death.
the extent of any loss suffered by the estate or dependants.
quantum.

Those matters were reserved for a separate trial.

The factual dispute

It was common ground that Dr Daish requested the chest radiograph. The central dispute was whether she told Mr Ahmed:

that the request had been made.
why the investigation was required.
that no appointment would be sent.
that he had to attend a walk-in radiology department.
when he should attend.

Neither Dr Daish nor Mr Ahmed had a reliable detailed recollection of the consultation.

Mr Ahmed stated before his death that he had not been told about the radiograph. Dr Daish relied principally on her usual practice, which was to tell patients when an investigation had been requested and explain how they should obtain it.

Dr Daish accepted that failure to give that information would amount to a breach of duty.

The significance of the ICE workflow

The investigation pathway depended upon patient action.

Generating the electronic request did not:

book an imaging appointment.
notify the patient independently.
prompt the radiology department to contact the patient.
alert the clinician if the patient failed to attend.
ensure that the investigation occurred.

The examination would take place only if the patient knew about the request and understood that attendance at a walk-in department was required.

The effectiveness of the request therefore depended on adequate communication during or immediately after the consultation.

The contemporaneous record

The consultation record documented:

Mr Ahmed’s presenting symptoms.
the clinical history.
examination findings.
oxygen saturation and peak-flow measurements.
the diagnosis of an asthma exacerbation.
prescribed inhaled treatment.
a planned review after two weeks.

The chest radiograph request appeared in the electronic record because it was automatically populated from the separate request form. It was not manually entered into the consultation plan.

The consultation note did not record:

any discussion about the radiograph.
the reason for requesting it.
advice to attend the walk-in department.
the recommended timescale for attendance.
a warning that no appointment would be sent.
that the follow-up consultation was intended to review the imaging result.

That silence was not considered in isolation. The court compared it with other entries from the same practice in which investigations and the advice given to Mr Ahmed were expressly documented.

The electronic chronology

The timing of the electronic records was important:

the consultation began at 11:14.
the chest radiograph request was completed at 11:28.
by 11:29, Mr Ahmed had left the consulting room and booked a follow-up appointment.
the consultation record was saved and closed at 11:32.
at 11:33, Dr Daish sent him a text about an additional prednisolone prescription made after he had left.

The later prescription was accepted to have been an afterthought. The court considered that this made it more plausible that the chest radiograph request was also completed after Mr Ahmed had left.

Unlike the additional prescription, however, no text or other communication informed him about the imaging request.

Evidence of usual practice

Dr Daish had no specific recollection of the consultation. Her evidence was that her usual practice was to:

explain that a chest radiograph was being requested.
advise the patient to attend promptly.
explain the walk-in process.
explain that the investigation was intended to exclude serious pathology.
arrange follow-up after sufficient time for the result to become available.

Evidence of usual practice may assist a court when neither clinician nor patient can recall a consultation. It is not, however, automatically determinative.

The court assessed that evidence against:

the contemporaneous clinical note.
the electronic timestamps.
the documented sequence of events.
the completeness of the record on other matters.
the absence of any recorded link between imaging and follow-up.
the comparison with other clinicians’ notes.
the probabilities arising from Mr Ahmed’s subsequent conduct.

The court found that the documentary and circumstantial evidence outweighed the evidence of usual practice.

Why the court found that Mr Ahmed was not informed

The court concluded on the balance of probabilities that Dr Daish did not inform Mr Ahmed about the chest radiograph.

Material considerations included:

Mr Ahmed had sought urgent advice and was worried about his health.
he had contacted the out-of-hours service the previous day.
he had previously completed requested blood tests under a similar patient-initiated system.
there was no evidence that he had undergone a chest radiograph before.
an investigation explained as necessary to exclude cancer was unlikely to have been ignored.
the consultation note contained no record of the discussion.
the chest radiograph did not appear in the documented plan.
there was no recorded connection between the investigation and the proposed two-week review.
the radiograph request was completed when Mr Ahmed had apparently left the consulting room.
another element of the management plan had demonstrably been added after his departure.

The judge nevertheless described Dr Daish as a caring and competent doctor and found that the omission was not representative of her usual practice.

Whether Mr Ahmed would have attended

The court found that Mr Ahmed would probably have attended for the chest radiograph if properly informed.

Relevant factors included:

his concern about his respiratory health.
the urgency with which he had sought medical attention.
his previous compliance with requested blood tests.
the novelty and significance of a chest radiograph.
the likelihood that he would have been told its purpose was to exclude serious disease, including cancer.
his subsequent attendance when another chest radiograph was requested in January 2020.

His failure to attend some other appointments did not displace the probability that he would have pursued an investigation explained as necessary to exclude cancer.

Contributory negligence

The defendant argued that Mr Ahmed had contributed to the outcome by failing to attend:

the follow-up appointment arranged for 27 February 2019.
a later asthma review.

The court rejected that contention.

Contributory negligence in clinical-negligence claims is possible but relatively uncommon. The defendant must establish that the patient failed to take reasonable care for their own safety and that the failure contributed to the relevant damage.

The cases relied upon by the defendant involved patients who:

had received clear advice.
understood the medical significance of that advice.
knowingly failed to take the recommended action.

Mr Ahmed’s position was materially different. On the court’s findings, he had not been told that a chest radiograph had been requested or that it was intended to exclude serious pathology.

The defendant could not establish that he understood the significance of failing to attend the later appointments. If his symptoms had improved following treatment, non-attendance was not shown to be unreasonable in the absence of knowledge about the outstanding imaging investigation.

He was therefore not contributorily negligent.

The court’s findings

The court determined that:

Dr Daish failed to tell Mr Ahmed that a chest radiograph was required.
she failed to explain that he needed to attend the walk-in radiology department.
Mr Ahmed would probably have attended if properly informed.
Mr Ahmed was not contributorily negligent.

Matters not decided

The parties agreed that a chest radiograph in February 2019 would have shown an abnormality and led to CT assessment and cancer treatment.

They did not agree whether earlier treatment would probably have:

cured the cancer.
prolonged Mr Ahmed’s life.
altered the course of the disease.
reduced his treatment burden.
prevented some or all of the claimed loss.

The judgment did not determine those issues. A finding that the investigation would have occurred is not equivalent to a finding that the eventual outcome would have been avoided.

Significance for clinical practice

Close the communication loop. Requesting an investigation is not enough where the pathway depends on the patient taking further action.
Explain the process. Patients should know whether they must book, attend a walk-in service or await an appointment.
Explain the purpose. The clinical reason for the investigation and the significance of non-attendance should be communicated proportionately.
Document the discussion. The record should distinguish between generating a request and telling the patient what to do.
Record the timescale. State when the patient should attend and when results are expected.
Link follow-up to the investigation. If a review is intended to consider the result, that purpose should be documented.
Use written reinforcement where appropriate. A text message, printed instruction or patient-portal notification may reduce ambiguity.
Do not rely solely on usual practice. Detailed contemporaneous documentation will generally carry greater evidential weight.
Consider system safeguards. Workflows without automatic reminders or non-attendance alerts create foreseeable risks.
Act on post-consultation decisions. If an investigation is added after the patient leaves, the patient must be contacted directly.

Significance for diagnostic services

Although the alleged breach concerned primary care rather than radiology, the case has implications for investigation pathways:

a request should not be assumed to result in attendance.
walk-in systems require explicit patient instructions.
non-attendance may be invisible where no appointment is created.
requesting and performing an examination are separate stages.
responsibility for communicating the next step should be clear.
uncompleted requests may require safety-netting or audit mechanisms.
organisations should consider whether digital systems can identify investigations that were requested but never performed.

Significance for medical records

The judgment illustrates that silence in a medical record is not automatically proof that advice was not given. Its evidential weight depends on context.

Silence may become persuasive where:

the note is detailed on other aspects of the consultation.
the omitted discussion would have been clinically important.
the clinician ordinarily records such advice.
comparable entries document similar discussions.
electronic timestamps suggest the decision was made after the patient left.
later actions are inconsistent with the advice allegedly given.
there is no independent communication confirming the plan.

Evidence of usual practice remains relevant, but it must be evaluated alongside the complete documentary chronology.

Practical documentation framework

When requesting imaging that requires patient action, record:

the investigation requested.
the clinical reason for requesting it.
any important diagnosis being considered or excluded.
whether the request is routine, urgent or subject to a suspected-cancer pathway.
whether the patient must book, attend a walk-in department or await contact.
where the patient should attend.
the recommended timescale.
what the patient should do if no appointment or result is received.
how and when the result will be reviewed.
any planned follow-up appointment.
relevant safety-netting advice.
confirmation that the patient understood the plan.
any written or electronic instructions sent after the consultation.

Educational case commentary only. It is not legal or medical advice and is not a substitute for the full judgment. The publication date above is the date of this commentary, judgment was delivered on 28 November 2025. The judgment determined preliminary issues concerning communication, probable attendance and contributory negligence. It did not determine cancer causation or quantum.