This case takes place in Rhode Island and involves a man in his early 60’s who had been prescribed Coumadin by his cardiologist. Subsequently, he required a prostate biopsy. The biopsy was coordinated between his urologist and his cardiologist regarding concerns of augmenting or eliminating Coumadin therapy in advance of the procedure. The use of Coumadin therapy was continued and sadly, due to this mismanaged Coumadin therapy, the patient bled out and died immediately following the procedure.