A senior citizen’s gallbladder surgery ended not in complications inside the operating room, but in the paperwork that followed. What began as a routine case of gallstones became a legal debate over a missing line in a discharge summary — one that failed to mention diabetes management for a known diabetic patient.

The woman had been under treatment for diabetes for several years before she was admitted for gallbladder surgery. Doctors planned a laparoscopic procedure, but when they encountered complex bile duct anatomy, the operation was converted to an open one — a standard, accepted surgical judgment. The surgery went smoothly, and she was discharged about a week later.

Her complaint came soon after: that the hospital had discharged her prematurely, ignored her diabetic condition, and failed to prescribe medication to control her sugar levels. A few days later, her wound became infected, requiring re-admission, repeated dressings, and fresh expenses.

The district forum found the hospital guilty, holding that it had ignored post-operative diabetes care and issued an incomplete discharge summary. The hospital appealed, arguing that the patient’s blood sugar was regularly monitored during admission, insulin was given when required, and the wound infection could equally have resulted from poor hygiene or the patient’s own failure to report for a follow-up review as advised.

The Delhi State Commission examined the records and the expert opinion from a medical board. The board confirmed that while the procedures performed were justified, the discharge summary indeed missed any mention of diabetes treatment. It also noted that surgical site infections are common among diabetic patients, particularly after open surgeries.

The Commission agreed that the omission was a record-keeping lapse—a form of professional misconduct, not medical negligence. It also observed that the patient had ignored clear follow-up instructions and returned to the hospital only after her wound had worsened, which amounted to contributory negligence. With no conclusive evidence linking the infection to poor hospital care, the finding of negligence was set aside.

IML Insight

Courts continue to draw a sharp line between documentation errors and medical negligence. A missing note in a discharge summary may attract criticism, but unless it directly affects patient safety, it remains a matter of professional discipline, not legal liability. For hospitals, though, the lesson is clear: in medical records, even one missing line can lead to a courtroom.

Source : Order pronounced by Delhi State Consumer Disputes Redressal Commission on 26th August, 2025.