This case involves an elderly male patient who was discharged from a hospital emergency room despite having lab results consistent with sepsis. Although the patient’s lab results triggered the hospital’s “severe sepsis warning” in the electronic medical record, these notifications were only received by the nurse, not the doctor. The nurse did not verbally communicate the sepsis warning notification to the doctor because he assumed the doctor was already aware. As such, the doctor never saw or heard the warning and the patient was discharged. The patient returned to the emergency room within 48 hours after discharge in full septic shock. He suffered a stroke and ended up in a coma. An expert in hospital administration was sought to address the proper protocols for staff when a patient like this presents themselves to the emergency room.