This case involves a minimally verbal 12-year-old female who presented to the same hospital system pediatric emergency room multiple times over a 3 month period. She was first diagnosed with pneumonia, given a 10-day course of amoxicillin and discharged from the emergency department. She returned and was found to have pneumonia with a large loculated pleural effusion. During this hospitalization, she was given IV antibiotics and given a 10-day course of antibiotics. Only one set of blood cultures were drawn and she was discharged while it was still pending. The patient was discharged and later returned to the emergency room with abdominal pain, low urine output, and constipation. She was discharged and expired at home a few hours later. An autopsy revealed the patient expired from bacterial meningitis secondary to pneumonia. Despite this patient’s nonverbal baseline and presumed inability to clear her infection, cerebrospinal fluid was never drawn and no head imaging was ever obtained. An expert in pediatric emergency medicine was sought to review the records and opine on the standard of care.