A 59 year old woman just completed successful heart transplant surgery and was set to be discharged home. She developed shortness of breath and an x-ray confirmed fluid had collected around one of her lungs. A simple procedure needed to be done to drain the fluid and allow her to breath easier. The x-ray was ordered in the early morning hours by a Resident and then not properly communicated to various Attending physicians who saw her later that same day. Both Attending physicians failed to appreciate the x-ray findings and her condition began to deteriorate. Unfortunately she suffered a respiratory arrest when the fluid was not drained which left her with brain damage. She was unable to care for herself independently and required attention by her children at all times. This matter was settled a few weeks before trial and allowed for a Trust to be set up to pay for home nursing care, medical equipment and home modifications for her to live safely.