This case involves a fifty-five-year-old male who presented to his primary care physician with complaints of worsening chest pain, chest pressure, and shortness of breath. Electrocardiogram results were abnormal and the PCP referred the patient to a cardiology group for further consultation. Additional testing was ordered, and the nuclear stress test technician reported in the patient’s chart that the patient could only withstand three minutes of treadmill testing. No immediate report to the physician was made and the patient was permitted to leave. Two additional lab diagnostic tests were ordered, and both came back abnormal. The patient was not contacted regarding these abnormalities, though, and was not asked to return for a follow-up consultation. Several days later, the patient died of a massive heart attack.