A man in his thirties presented to a South Florida hospital suffering from ketoacidosis, which is a serious diabetes complication where the body produces excess blood acids. A urinalysis also confirmed the presence of a severe urinary tract infection for which the physician documented the patient’s need for antibiotics. Unfortunately, neither the hospital staff or physician informed the patient of the infection, and he was later discharged without ever receiving any antibiotics. The following day he experienced a cardiac arrest and eventually died as a result of the septic shock, resulting from the untreated infection.