This case takes place in Iowa and involves a child with a chronic medical condition who was placed in the care of foster parents through a foster service. Due to the child’s state, she had to have a permanent tracheotomy in place to assist with her breathing. While the child was with her foster parents her tracheotomy came out on multiple occasions. The medical service that was hired to assist the foster parents was able to replace the tracheotomy and restore breathing for the child each time the tracheotomy was dislodged. However, on the one occasion they were unable to replace the tracheotomy and the child went without oxygen for an extended period of time, resulting in permanent brain damage. The foster service had a medical care plan that was instituted when the child was first placed with the foster family, but it was never properly implemented.