The Difficulty Of Brief Medical Records And AI

I have previously written about cases where the accuracy of medical records has been brought into question. In the case of Shaheen v Dr Daish [2025] EWHC3056 we have a case where the court had to determine the likely content of a GP consultation in February 2019 where the note was brief and lacking in information.

Briefly, the case related to allegations of a delay in diagnosis of a lung tumour arising from the failure to carry out a chest x-ray. Whilst the parties agreed that had an x-ray been done it would have revealed an abnormality that would have led to a CT scan being recommended, it remained in dispute as to whether subsequent treatment would have altered the outcome.

However, the trial was concerned only with facts of events at the GP consultation.