This case involves a female patient who presented to her primary care physician with complaints of abdominal pain, nausea, heartburn, and vomiting. During the visit, the patient noted that the symptoms had been present for over a month, but that they had gotten much worse over the course of the preceding week. The physician ordered a full upper GI series and prescribed heartburn medication. During a subsequent visit to the same doctor’s office for an unrelated issue, there was no follow up on the earlier gastrointestinal concerns. Over the course of several months, the patient presented to a number of other physicians for various concerns, none of who followed up on her recurrent intestinal symptoms. Eventually, the patient presented to the emergency room for severe gastrointestinal symptoms. After undergoing a series of testing that indicated the formation of a bowel obstruction, the patient was admitted to the hospital. Her condition continued to deteriorate over the next few hours, and she was eventually taken into surgery. During surgery, it was discovered that a significant portion of the patient’s bowel was necrotic due to a lack of blood flow caused by the bowel obstruction, which was related to an undiagnosed malformation of her digestive organs. It was alleged that more thorough workup by her treating physicians prior to her ER visit could have identified the issue before it led to bowel necrosis.