This case involves a man who retained a stone in his bile duct following a surgery on his gallbladder. An endoscopic visualization procedure known as an ERCP was performed, after which physicians noted that there may have been a perforation in the patient’s duodenum. Despite the fact that the perforation was identified, it was not treated directly, with doctors orders for conservative monitoring and antibiotics. Nevertheless, the patient continued to suffer difficulties related to the perforation that necessitated additional surgeries, an extended hospital stay, a months-long rehabilitation period, as well as disfiguring scarring from the repair procedures. It was alleged that the patient’s duodenal perforation should have been treated more aggressively, and that earlier intervention would have prevented his negative outcome.